Nursing Care Lacks of Knowledge

ARRANGED BY:

ALRI LESTARI (2014901053)

POLITEKNIK KESEHATAN KEMENKES TANJUNGKARANG

JURUSAN KEPERAWATAN TANJUNGKARANG

PRODI PROFESI NERS TANJUNGKARANG

TAHUN AKADEMIK 2020/2021

 Nursing Care lacks knowledge

1. Assessment

a. Biodata

1). Client Identity

Name : Mr. W.R

Age : 73 years old

Gender : Male

Address : South Lampung

Region : Protestant Christians

Status : Married

Job : Farmers

Education : High school

Medical Record : 72897

Date of Hospitalized : May 5th, 2010 2:30 PM

Date of Assessment : May 7th, 2010 4:0 PM

Medical Diagnosis : CKD

2). In Charge

Name : Mrs. C.R

Age : 42 Years

Gender : Women

Job : Housewives

Relationships with clients : Client's Child

b. Main Complaints

Body feels weak

c. Medical history

1). Current history of the disease

The client is taken to the Hospital because of swelling In both legs that the client

has experienced 1 month before entering the hospital but has not been taken to the

Hospital because the client is still active as usual. On May 5, 2010 the client was

taken to the Hospital because the client complained that both of his legs were getting

swollen and difficult to move, after being examined by the client doctor

recommended for further treatment.

When reviewed (June 7, 2010, 4:00 p.m.) The client complained of swelling in

both legs, making both legs difficult to move. Clients say the body feels weak,

coughs are slimy, shortness of breath, nausea and vomiting, appetite is reduced, and

clients also say itching in the skin (Feet and hands)

2). History of disease

Client Already 4 years suffering from Diabetes Mellitus disease, Client often in

and out of hospital because of this disease, the client has been 4x in Kerena Hospital

Diabetes Mellitus Disease

 3). Family history of illness

The client's family has hereditary diseases such as Diabetess Mellitus.

d. Psychosocial history

The client's relationship with the family is well established. Clients always involve

themselves in community activities. Clients are cooperative in care, clients and families

say not knowing about the disease that the client is suffering now, the client's family is

wondering about the disease that the client is suffering now.

e. Spiritual History

Before illness the client was active in spiritual activities in his congregation. The

Client believes that his illness is simply an ordeal from God and the client also believes

that God will always provide healing to the client through treatment and treatment in the

Hospital.

f. Daily Activities

1)     Nutrients

Appetite : Less

Frequency : 3 times a day

Types of food : Porridge, Fish, Vegetables and Fruit

Portions of food are not spent, Only eaten 2 Tablespoons, clients eat assisted by

nurses and families, clients say nausea and 1time vomiting

 2) Fluid

Types of Beverages : White Water

Frequency : Client Drink1000cc of water (4 large glasses)

3) Elimination Pattern

Defecation

Client has not defecate since entering the Hospital BAK

Frequency : 1-2times/day Total 600cc

Color : Reddish yellow

4)          Activity Patterns

Bedrest clients, all client activities are assisted by family and nurses.

5) Personal Hygine

Clients only on laps in bed are carried out by family and nurses

6)      Rest and Sleep Patterns

Night Sleep 8 to 9 hours, and nap 3 to 4 Hours

7)     Dependency

Clients Never conserve alcohol

Client Smoking, quit smoking 4 years ago

Clients Have long taken Hypertension drugs and diabetes Mellitus

2. Physical examination

a. General circumstances

Awareness : Compos Mentis

 B. TTV :

Blood pressure: 140/70 mmHg

Pulse : 72 beats/ minutes

Respiration : 24 beats/ minutes

Body Temperature : 36.4ºC

Weight : 65 kg

height : 165 Cm

DATA ANALYSIS

DATA Etiology Problem

Subjective Data: Lack of information about Lack of knowledge

 Clients say they've had the condition and handling

Diabetes Mellitus since 4 years

ago

 The client says he's been

hospitalized with the same

illness.

 The client's family says it does

not know about the illness

experienced by the client

Objektive Data:

- Clients and family ask about his illness

B. Nursing Diagnosis
 lack of knowledge related to lack of information about the disease and its treatment

characterized by

Subjective Data:

 Clients say they've had Diabetes Mellitus since 4 years ago

 The client says he's been hospitalized with the same illness.

 The client's family says it does not know about the illness experienced by the client

Objektive Data

 Clients and family ask about his illness

C. Intervention
a. Explain the meaning of Diabetes mellitus
Rational:
Increase client knowledge and reduce anxiety

b. Explain the causes of diabetes mellitus

Rational:
Increase client knowledge and reduce anxiety

c. explain about the signs, symptoms and complications of diabetes mellitus

Rational:
Prevent client severity

d. Discussion about therapy and its options

Rational:
Give an overview of therapy and its options

IMPLEMENTATION AND EVALUATION

 DAY 1
Implementation Evaluation

1. Explaining The Meaning Of S:

Diabetes Mellitus  The client understands about the
2. Explaining The Causes Of disease
 The client can explain again about
Diabetes Mellitus
the understanding, signs and
3. Explaining The Signs, symptoms of diabetes mellitus
Symptoms, And
O:
Complications
4. Discussing Therapy And Its  Client have not been able to choose
Options what is the right therapy to reduce
complications in diabetes mellitus
 The client's family has asked again
about the client's illness

A : Problem not Resolved

P: Continue the intervention
a. discussions with therapeutic clients
in the prevention of diabetes
mellitus
 IMPLEMENTATION AND EVALUATION
DAY 2
Implementation Evaluation

1. Explaining The Meaning Of S:

Diabetes Mellitus  The client understands about
2. Explaining The Causes Of the disease.
Diabetes Mellitus  Client can explain again
3. Explaining The Signs, about the understanding, signs
Symptoms, And and symptoms of diabetes
Complications mellitus
4. Discussing Therapy And Its  Client say they will do
Options Diabetes melltus gymnastics
every week
O:
 clients can already choose
what is the right therapy to
reduce complications in
diabetes mellitus
 The client's family has asked
again about the client's illness

A : The Issue is resolved

P : Stop Intervention