3 GROUP of A3

rd
1. Merytania Pramudita
2. Fiadela Natalia
3. Niken Rohdiyah
4. Annisa
5. Siti Nur Kholidah
6. Salsabila Ridni
7. Annisa Alivia
Case Study
A client, called mr. T, was cared for in a public hospital private
care room, the client was treated with complaints of limp body
almost fainted. Lately clients often complain of thirst, often BAK,
often feeling hungry, weight down 4 kg in one month and BB
client is now 68 kg. Complaints that the client feels are easily
tired, likes to feel tingling in the fingers or toes, and feel pain
when on the move and feels pain on the middle head with pain
scale obtained that is 6. The family says that Mr. T has a history of
DM 4 years ago. The client's feels cold, the client appears pale,
the client's mucosa appears dry, and the client appears tremor.
Laboratory check results of blood sugar 41 mg / dl. Previously
clients were given insulin and metformin. Client medical
diagnosis: Hypoglycemia
Assessment : Focus Data
Subjective data
• The client said his body was weak
• The client says feeling tired
• Clients feel unwell
• The client says dizzy
• The client says headache
• T: <20 minutes
• Clients say they often feel hungry
• The client said BB dropped 4 kg in one month
• The client says it's easy to get tired
• Clients say they like tingling on the fingers or toes
• The client said he had a history of DM 4 years ago
Objective Data
• GDS: 41 mg / dl
• Previously, clients took metformin in excessive doses
• TTV:
• TD: 140/80 mmHg
• N: 102x / minute
• RR: 20x / minute
• S: 35 ° S
• Cold
• The client looks pale
• The client lies limp
• The client's mucosa is dry
• The client looks tremor
• BB client now: 68 kg
• BB before: 72 kg
• Medical diagnosis: Hypoglycemia
NURSING DIAGNOSIS

• Nutrient imbalance is less than the body's needs is related to

Inability to absorb nutrients
• Acute pain is related to biological injury agent
• Ineffectiveness of peripheral tissue perfusion is related to
Diabetes militus
• Fatigue is related to physiological lethargy: hypoglycemia
PLANNING 1
Diagnosis : Nutrient imbalance is less than the body's needs is
related to inability to absorb nutrients

OUTCOMES
• objectives and results criteria : After nursing action for 2x24
hours, it is expected that the problem of nutritional imbalance
is less than the needs of the client can be resolved, with the
results criteria:
• BB normal client returns
• Normal GDS results: <200 mg / dl
• Clients do not take anti-diabetic drugs in excess doses
Intervention

Independent :
• Monitor daily calorie food intake
• Monitor the client's weight regularly
• Assess the client's GDS before and after 1 hour of feeding
• Weigh the patient at the same time every day
• Assess the patient's favorite food, whether it is personal
preference or that is recommended by culture and religion
• Help patients to eat or drink patients
• Create a pleasant and soothing environment
• Serve food interestingly
• Give an explanation to the client / family of the client in taking
anti-diabetic medication according to the recommended
dosage
Collaboration:
• Collaboration with the team of doctors in determining the
dose of antidiabetic drugs to clients
• Collaboration with nutritionists in determining the daily
calorie intake needed to maintain a predetermined body
weight
PLANNING 2
Diagnosis : Acute pain b.d biological injury agent
Outcomes :
• After nursing action for 2x24 hours, it is expected that the
acute pain problem in the client can be resolved, with the
results criteria:
• The client does not feel pain in the head while on the move
• The client does not feel dizzy
• The client does not feel a headache
• Client pain scale 0
Interventions
Independent
• Assess client pain scale
• Give a calm environment
• Set the client's sleeping position: fowler
• Teach deep breathing relaxation techniques
• Conduct a comprehensive pain assessment
including: P, Q, R, S and T
Collaboration:
• Collaboration with a team of doctors in the
administration of analgesic drugs
PLANNING 3
Diagnosis : Ineffectiveness of peripheral tissue perfusion is related to
Diabetes militus
Outcomes :
• After nursing action for 1x24 hours, it is expected that the problem
of ineffectiveness of client peripheral tissue perfusion can be
overcome, with the results criteria:
• TTV is within normal limits:
• TD: 120/80 mmHg
• N: 60-100 x / minute
• S: 36.5-37.5 ° C
• RR: 16-24x / minute
• The client's roots are not cold
• Clients don't feel tingling anymore
• The client is not tremor
interventions
• Independent :
1. Assess the level of client awareness (GCS)
2. Review the TTV client
3. Assess GDS levels before and 1 hour after therapy
4. Maintain the effectiveness of the client's airway
5. Give a supine position
6. On the client
7. Provide information to the client's family about the
disease and its handling
8. Teach diabetes gymnastics clients
• Collaboration:
Collaboration with a team of doctors in the administration of
neurotropic vitamin drugs
PLANNING 4
• Diagnosis : Fatigue is related to physiological lethargy
(Hypoglycemia)
• Outcomes :
After nursing action for 1x24 hours, it is expected that the
problem of fatigue on the client can be resolved, with the results
criterion:
1. The client does not feel weak
2. The client does not feel tired
3. Clients feel well
Interventions
• Independent:
1. Assess the physiological status of the patient which causes
fatigue according to the age and development context
2. Review the TTV client
3. Limit activity adequately
4. Encourage clients to do light activities first
5. Give education to client / family clients by explaining the
relationship between fatigue and disease process / condition
• Collaboration:
Collaboration with nutritionists in providing high-energy
food intake