Family Nursing Care Report of Mr.

M Family
With Hypertension Medical Diagnosis
Komp. Ratu Zaleha gang. Ki Hajar Dewantara 9

A. Assessment

1. General Data

The Head of Family : Mr. M

The Head of Family address : Komp. Ratu Zaleha
The Head of family Occupation : Driver
The Head of Family Education : SMA

a. Members of Family:
No Name Sex Relationship to the head Age Education
of the family

1 Mr. M Male Husband 45 years old High School

2 Mrs. R Female Wife 50 years old S1

3 Mr. M Male 1st Child 25 years old Student

4 Mr. M Male 2nd child 23 years old Student

Genogram

b. Type of family
 Mr. R families is the nuclear family type (Nuclear Family) consisting of father (Mr.
M), mother (Mrs. R), and a son (Mr. M and Mr.M). All live at home.

c. Ethnic background

Mrs. R’s family is Banjarese

d. Religion

Mrs. R and the whole of family members is Islam

e. Socio-economic

Source of family income comes from Mr. M works as a driver get 800.000/month.
And coming from Mrs. R is working as teacher of elementary school can get
1.500.000/month.

f. Family recreation activities

Family of Mrs. R does not have a specific timetable for visiting tourist spots. In
fact hardly ever recreation due to the work to be done each day.

2. History of development family

a. Stage of family development

Current stage of development of the Ny family. R is at the development stage of

young adulthood.

b. Problem of family development

Family said that there are still many tasks such unmet family welfare of the family.

c. Health status of each family member

 In the last 1 month client admitted to the hospital. She always in trouble with his
health that is felt dizzy and headache. If the disease relapses, client immediately
checked his blood pressure. While Mr.. M is currently in good health. Mr. M and
Mr. M is in a healthy condition.

d. Medical and nursing history of family member

Client’s family has a history of hypertension. Hypertension suffered by Mrs. R is a

hereditary disease from their parents, while hypertension is not a hereditary disease
of the family Mr. M. The family had ever medical history.

3. Home and Environtment

a. Housing

Land area :8x20m

House area: 4 x 7 m

The type of permanent home. The floor is made of cement with a roof of
corrugated iron. There are ventilation with adequate lighting and four windows
with one's own home state. Had three of bedroom, living room, dining room, and
toilet.

Kitchen Toilet

Bedroom 3
Dining Room

Bedroom 2

Bedroom 1 Living Room

b. Kind of neighborhood and activities

 Family had a good relationship with her neighborhood and had activities in
community.
c. Transportation Facilities
Member of family use motor cycle to go somewhere.
d. Social activities and communication
The family had good social activities and use Banjar language to communication.
e. Social and health facilities
If family got sick, they went to healh service like clinic or other.

4. Structure of Family
a. Interaction pattern among family member/communication
Communication language used is Indonesian and Banjar. Communication between
family members quite well, where if there is a problem in the family is always
solved by the deliberation.
b. Domain family member in term of decision making
Patterns of decision-making in the family is more domain by Mr.. M. However,
before a decision is taken, it must first be discussed together in order to reach
agreement.
c. Role of Family
- Mr. M has an informal role as a member of society. While formal role was as
head of the family, husband, and father as well as a personal driver.
- Mrs. R has an informal role as a member of society, while formal role was as a
wife and elementary school teachers.
-Mr. M and Mr.M has a formal role was as a child.

5. Function of Family
a. Function of affective
Family of Mrs. R give love each other. And respect.

b. Function of social
Interaction between family members well established, each member of the family
attention and ethical norms of conduct, both in the family and in society.
 c. Function of healthcare
1). Knowing about disease / health condition
Client’s family said that he often felt headache and dizziness even when
teaching in the classroom.
2). Making decision with respect to taking appropriate health action
If client get felt headache or dizzy, family bring she to the clinic.
3). Providing adequate nursing care to sick family member
If there are family member got mild disease just care at home. If the pain does
not improve they took to be treated at the clinic.
4). Providing a home environment conducive to health mantenance and personal
development
Family always care to environtment of house to keep healthy.
5). Utilizing communit resource for health care
If a family member was sick, in which case the pain is still tolerable and do not
require to get care at home, they only buy medicine at apotek, but if the
circumstances are sufficient and necessary treatment then family directly go to
the clinic or hospital.

d. Function of reproduction
Client had 2 son ,there are : Mr. M and Mr. M

e. Function of economic
Family income money to need of family from Mrs. R and Mr. A. She hopes that
can enough to their chidren’s education and daily need.

6. Stress and coping of family

a. Short and long term stressors
1). Short term stressors
Client said that headache and dizziness suddenly.

2). Long term stressors

Client said that she stressed that the illness can impact on her health.
 b. Family response to the situation or stressors
1). Short term stressors
Family always checked client’s blood pressure
2). Long term stressors
Client taking hypertension medication regularly, and also always provide a
cucumber at home.

c. Coping strategy
If there are problems in the family, always discussed among family members,
although in the later decision will be taken over Mr. M as the head of the family.

d. Disfunctional adaptation
If have a problems, family was never completed with violence, but always quietly
so that no one conflict in the family.

7. Physic exam
General Condition
Blood pressure : 180 /100 mmgh
Heart rate : 92 x / minute
Respiration : 20 x / minute
Temperature : 36oC

1. Head

a. Hair and Scalp

Head structure symmetric, hair’s color is black and little white thin
contribution. There was not lesion and mass.

b. Eyes and Sight

Eye Structure was Symmetric right and left. Conjunctiva anemis, sclera
looked white, pupil looked isokor and there was not jaundice in eyes.
 c. Nose
Structure was symmetric, there was not inflammation or epistasis.

d. Mouth
Mouth looked moist and there was not irritation or bleeding in the mouth

e. Ear
The structure of ears was symmetric, there was not secret that disturb hearing,
serum was minimum no pain on ears.

2. Neck
Neck was symmetric, there was not limitation of motion in the neck, Jugular Vein
palpated no increase, there are no enlargement of the Thyroid Gland and no
enlargement of the Lymph Node.

3. Abdomen
Inspection : seemed clean no lesion, flat abdomen shape
Palpation : No mass and an enlarged liver and lymph
Percussion : Tympanic Sound
Auscultation : Bowel peristaltic 8 x / Minutes

4. Genitalia

Client is Female and have been married and had 2 son, are Mr. M and Mr. M.

5. Extrimities
 Structure of the upper and lower extremities right and left was symmetric, no bone
abnormalities such as deformities and fracture. The ability of upper and lower
extremities is weak with muscle strength scale

5555 5555
5555 5555

B. Data Analysis

No Data Etiology Problem

1. Subjective data : Innability to Deficit of knowledge
-Client said that she doesn’t know recognize the health about hypertension
caused of hypertension problem in family
-Client said that sometimes she felt
dizzy and stiff on the nape of neck
-Client said that she likes salty food

Objective data :
-Vital sign :
Blood pressure = 180 / 100 mmhg
Pulse = 92 x / minute
2. Subjective Data : Inability modify Risk of
-Client said that her mother had suffer environtment’s hyperglikemia
diabetic mellitus family to increase
-Client said that she likes sweet food health of family

Objective Data :
-Client’s blood glucose = 285

C. Scoring

1. Family Nursing Diagnosis I

No Criteria Calculation Score Justification
1. Nature of the problem 3/3x1 1
 pressented
2. Modifiability of the 2/2x2 2
problem

3. Preventive potential 3/3x1 1

4. Salience scale 1/2x1 1

Total 5

2. Family Nursing Diagnosis II

No Criteria Calculation Score Justification
1. Nature of the problem 3/3x1 1
pressented
2. Modifiability of the 2/2x1 1
problem

3. Preventive potential 3/3x1 1

4. Salience scale 0/2x1 0

Total 3

D. Problem Priorities

1. Deficit of knowledge about hypertension related to Innability to recognize the health

problem in family

2. Risk of hyperglikemia related to Inability modify environtment’s family to increase

health of family
E. Planning

No Day/date Diagnosis Goal Intervention Rational

General Spesific
1. Deficit of After visited 1.After 1.Measurement 1.To know
knowledge by nurse, visited by of vital sign general
about health nurse above condition of
hypertension condition of 2-3 days, client
related to Mrs.R is family of
Innability to increase. Mr. M can 2.Give family 2.Family
recognize the be know knowledge can be know
health about about the about sign
problem in hypertension characteristics and
family disease. and treatment symptom of
for the hypertension
hypertension. disease and
2.After give can give
explanation treatment
about caused for client.
hypertension
, family can 3. Discuss 3.To know
keep food together with the caused
with low-salt client about the hypertension
for client’s caused of client.
diet. hypertension.

4. Give an 4. With the

explanation to explanation
the client and family can
family giving to know and
correct diet for understand
patients suffer about giving
hypertension. low-salt diet
for client.

F. Implementation

No Day/date Diagnosis Implementation Signature

1. Deficit of 1.Measurement of vital sign
knowledge about
hypertension 2.Giving family knowledge
related to about the characteristics and
Innability to treatment for the hypertension.
recognize the
health problem
 in family 3. Discussing together with
client about the caused
hypertension.

4. Giving an explanation to the

client and family giving correct
diet for patients suffer
hypertension.

G. Evaluation

No Day/date Diagnosis Evaluation

1. Deficit of knowledge S =
about hypertension related -Client said that can be know about
to Innability to recognize characteristic and treatment for
the health problem in hypertension.
family -Client said that will decrease to
consumption salty food

O=
-Client’s vital sign
Blood Pressure :
Pulse :
Respiration :
Temperature :

A=

P=Continue intervention
- Measurement of vital sign
- Give correct diet for patients suffer
hypertension.