TREATMENT GIVEN TO MRS.

S PATIENT SUFFERING NUTRITIONOUS PROBLEM

AT MELATI 1 ROOM AT LOCAL HOSPITAL dr. LOEKMONO HADI KUDUS

A. ASSESSMENT
Day/Date : Monday, July 1, 2019
Time : 14.15
By : Mrs. AM

1. PATIENT’S IDENTITY
a. Patient’s Identity
Name : Mr. S
Date of Birth : October 20, 1956
Sex : Male
Religion : Islam
Education : Primary School
Occupation : Entrepreneur
Race/Nationality : Javanese/Indonesian
Marital Status : Married
Address : Rejosari 05/03, Dawe, Kudus
Med Rec Number : 700XXX
Diagnosis Diabetes Mellitus

b. The Concerning Person’s Identity

Name : Mr. M
Date of Birth : April 15, 1950
Sex : Male
Religion : Moslem
Education : Primary School
Address : Rejosari 05/03, Dawe, Kudus
Relationship to the patient : The husband

2. MEDICAL HISTORY
a. Main Complaint
Feeling itchy
b. Heretofore medical record
The patient said she has felt itchy since before visiting the hospital and was
begun by vomiting. On June 25, 2019, the patient was sent off to Loekmono
Hadi hospital, Kudus. After arriving at ICU, she was treated by the concerning
medical officer with result TTV : TD : 190/110 mmHg, HR : 100 x/m RR : 20
x/m, T : 37.2, SpO2 : 99 and GDS : 156 mg/dl. In the ICU, she was given a
therapy through initial instruction of the doctor and it was continued. Then, the
medical diagnosis made them moved to be inpatient in Melati 1 room.
c. Previous medical record
The patient admitted she suffered DM and HT
 d. Family medical record
The patient’s family said not to have any medical record as suffered by the
patient, to suffer DM and HT.
e. Record of Diseases
The patient admitted to not have any medical, dietary, air, and other allergies.

3. Functional pattern
a. anthropometry : Tb = 155 cm
bb = 50kg
lila = 24,1 cm (N = > 23,5 cm)
imt = BB (kg)/TB2 (m) = 50/1,552
= 20,8 (N = 18,7 – 23,8)
BB ideal = 47,8 kg
b. Bio-chemical : June 27, 2019. 16.00 – 16.33 Western Regional Time
hb = 11,9 g/dl
gds=124
Creatinine = 0,58 mg/ds (N=0,5-1,2)
Sodium = 132,2 (N=135-145)
Calcium= 3,61 (N= 3,5-5)
C. Clinical sign: the skin turgor returns quickly, normal mouth mucosa,
moderate pale, and no edema
D. Dietary: soft dietary, 3 times a day, eat ½ - 1 portion

Remark Before feeling painful During feeling

painful
Frequency 3 times a day 3 times a day
Types rice, side dishes, vegetables, sweet tea, and pure water Porridge, side
dishes, vegetable, tea, and pure water
Portion 1 portion ½ - 1 portion
Drinking Pattern 10 glasses/day, pure water, and tea 6-7 glasses/day,
pure water, tea, and milk
Weight 52kg 50kg
Complaint No itchy, nausea, vomiting,
and loosing appetite
4. Physical check
a. General condition = feeling good
b. Consciousness = the patient was at compos mentis consciousness (fully conscious).
GCS assessment (Glasglow Come Scale).
1. Eyes could open and see well. Scored 4.
2. Motoric was shown by having good movement.
3. Verbal was shown by clear and good vocal sounds.

C. Vital signs = Blood pressure 150/110 mmHg. Body temperature 36.7oC. HR : 70x/M. RR :
20x/M.
D. Height and Weight = before and after being sick (H 155 cm and W 52 Kg and after being
sick the W was 50 kg).
F. Head and hair = shaped mesochepal, symmetric, no injury, no white hair, no crumpled, a
bit dirty.
G. Face = No pale, symmetric, and no inflammation.
H. Eye = Asymmetric, Icteric Sclera, not anemic conjunctiva, no curving, no black eye bag.
I. Nose = Symmetric and no polyp
J. Mouth = not cyanosis mouth color, two broken teeth, dirty, wet lip, and no bleeding
gum.
K. Ears = symmetric, a bit serumen
L. Neck = no enlarging thyroid
M. Chest = Lungs/Thorax -> I = symmetric, exhaling and inhaling normally, no chest
retraction
P = Right and left vocal fremitus were equally strong and no
pain, no inflammation
P = Sonor
A = Vesicular
Heart - > I = no ictus cordis
P = Palpable ictus cordis (ic 4-5), no pain on chest pressure, symmetric
P = Fading
A = Not heard, regular
Abdomen - > I = symmetric, no injury
A = Hypoactive colon noise
P = No palpable pain
P = Tympanic
Genital -> Not checked
Extremity - > Nail inspection : white, long, dirty, no edema
Functional ability: right 5.2, left 5.2. A) upper extremity = scale of muscular
extremity upon sinistra and dextra were respectively 5 indicated by ability to grab strongly,
B) lower extremity = sinistra and dextra were 2 for each. Being unable to move
independently and needed support. Moving/walking by using wheel chair. C) On left hand,
there was attached an infusion. No infectious sign on the infusion penetration. No exaggerate
pain while being penetrated by the infusion.
a. HASIL LABORAT

Parameter The results Unit Reference valve

Hematologic

HB H11,9 9/dL 11,7-15,5

Leukosit 16,94,29 103/uL 36-11.0

Eritrosit 4,29 106/uL 4,2-5,4

MCV L 76,5 FL 80-100

27,7 PG 26-34

MCHC 11 36,3 32-3

TROMBOSIT H 349 103/uL 150-400

RDW-CV 11,9 11,5-14,5

RDW-SD L 32,5 FL 35-47

 POW 12-6 FL 9,0-130

MDV H 10,5 FL 6,8-10-10-0

D-LCE 29,7

HEMATOFRIT L 32,8 35-47

COUNT TYPE

NETROFIL H 83,70 50,0-70,0

LIMPOSIT L 7,50 25,0-100,0

MONESIL 118,50 2,0-8,0

BESOFIL L 0,10 2-4

0,20 0-1

b. DATA ANALISIS

NO Day/date/time Focus data Problem Etiologic TTD

(DS and DO)
1 Monday, July 1. DS: Blood Delays is
1st 2019 -The patient said the body is glucose cognitive
itching all over the body level risk development
- The patient said nausea of (00179)
- The patient said no appetite intability domain 2
class 4
2. DO:
A. Heigh : 155cm
Weigh : before getting sick
50
When sick 50
IMT : 20,8

B. HB : 11,9
GDS : 124

C. Skin turgor return quicky

mount mucosa is normal,
looks weak, looks edema
D. Mushy diet 3x a day

Nursing Diagnosis
 Blood Glucose Level : Risk Of Instability Associated with Delays in
Cognitive Development

Intervention

No Date DX NOC NIC Signature

1 Monday,July 1 After it being Nutrition Monitor

conducted nursing
1st 2019 actions along 3x8 Weigh the patient
hours,expect achieve weight
blood glucose rate : the Teach diet recipe
risk of instability can
be reduce by the target Teach patient’s the
outcome scale being name of foods that
maintain at level 2 to 4: are in accordance
with recommend
230001 Blood Glucose diet.
230004 Glycocyte Treatment
Hemoglobin Management
230007 Glucose Urine Determine what
medication is
need,and administer
it according to a
prescription or
protokol

Increase familly
involvement

Encourage the
patient’s family
members to help in
developing a nursing
plan

IMPLEMENTATION

Monday, July 1, 2019

... 14.30 1. Nutrition monitoring

Subjective data: the patient said to voluntarily measure his weight.
Objective data: weight = 50 Kg

... 14.45 2. Improving family involvement

Subjective data: the patient family said to voluntarily assist in developing nursing plan.
Objective data: the patient family seemed voluntarily assist in developing nursing plan.

... 15.00 3. Teaching and issuing the dietary program

Subjective data: the patient said to voluntarily be taught about dietary plan to assisted.
Objective data: the patient was voluntarily taught

... 15.15 4. Curing management; metformin 500 mg

Subjective data: the patient said to voluntarily be given oral medicines included Metformin
500 mg.
Objective data: the patient drank the medicine voluntarily included Metformin 500 mg.

2. Tuesday, July 2, 2019

... 11.00 1. Monitoring nutrition

SD: the patient said to voluntarily measure his weight.

OD: weight = 50.2 Kg

... 11.15 2. Improving family involvement.

SD: the patient family voluntarily assisted in developing the further nursing plan.
OD: the family voluntarily assisted in the further plan.

... 11.20 3. Curing management; Metformin 500 mg

SD: the patient was voluntarily given oral medicine included Metformin 500 mg.
OD: the patient voluntarily drank oral medicine included Metformin 500 mg.

3. Wednesday, July 3, 2019

... 13.00 1. Monitoring nutrition

SD: the patient voluntarily measured his weight and checked his blood level/GDS
OD: weight = 50.7 Kg, GDS = 110

... 13.10 2. Teaching; preparing dietary plan

SD: the patient said to voluntarily be taught again about dietary plan
OD: the patient was voluntarily taught again about his dietary plan.

... 13.15 3. Medicine management; Oral medicine provision included Metformin 500 mg.

SD: the patient said to voluntarily be given oral medicine included Metformin 500 mg.
OD: the patient was voluntarily given oral medicine included Metformin 500 mg
 EVALUATION

Number Date and Time Evaluation Signature

1 Monday, July 1, S : The patient told she was

2019. feeling itchy all over her body.

15.30 O : The patient was crying since

it was painful. She seemed
rubbing. She looked pale. The
nutrition monitors were weight 50
= Kg, GDS = 124.

A : Nutrition problem had not

been overcome.

P : Keeping the intervention by

giving analgesic.

2 Tuesday, July 2, S : The patient felt itchy on

2019. several limbs (Chest and Hands).

11.35. O : The patient seemed rubbing it.

The patient looked pale. Nutrition
monitors were weight 50.2 Kg.

A : Nutrition problem was

partially overcome.

P : Keeping the intervention by

giving analgesic.

3 Wednesday, July 3, S : The patient said her itchiness

2019. was decreasing.

13.20. O : The patient seemed calmer

than previous one. Nutrition
monitors were weight = 50.7 Kg,
GDS = 110.

A : Nutrition problem was

overcome.

P : Stopping the intervention.