NURSING CARE PLAN MR.

ASSESSMENT A. SELF IDENTITY 1. Client Name Age Gender Religion Education Job Marriage status Address No CM Informant Date of assessment : Mr. S : 61 years old : Male : Islam : Senior high school : Jobless : Married : Karangasem 1/VIII Laweyan Surakarta : 234481 : Client, family, and medical status : December, 4th 2012

Date come to hospital : November, 30th 2012 Medical diagnose 2. Care - taker Name Age Job Address Clients relation : Mr. B : 34 years old : Private / laborer : Karangasem 1/VIII Laweyan Surakarta : Child : Hernia Incarcerata, DM, and CKD

B. HEALTH HISTORY 1. Chief complain : Client complaint that he has dypsnea, no cough,

no sputum, pain on the wound in lower right abdomen if he want to move , intermittent, like stab of needle, sometimes at the morning, at noon or night, scale 4.

2. Current health history

: before hospitalization client is suffered diabetes

mellitus, enter to emergency room with mass on scrotum, then enter to multazam ward post op hernia incaserata. 3. Past health history Genogram : : Diabetes mellitus Explanation : : Female : Male : Death : Close family : One house : Client

4. Family health history

Family havent health history like client. 5. Case management History :

Date

Dx. Medical

Diagnostic support

Therapy / intervention

C. CURRENT ASSESMENT ( GORDON FUNCTIONAL PATTERN ) 1. Health perception health management : Health is godness, if client is sick, he come to family docter. 2. Nutritional metabolic pattern: Food Intake: a. Before hospitalization : client eats anything 3 times / day full portion. b. During hospitalization : client eats diet porridge rice DM. Drink Intake :

a. Before hospitalization : client drink 4 5 glass/ day 200cc, mineral water or tea b. During hospitalization : client drink 3 4 glass / day 150cc, mineral water or tea, infusion ringer laktat 16 drop / minute on right hand. 3. Elimination pattern a. Bowel movement Before hospitalization : 1 times / week, color : yellow, odor : tipically, tekstur : soft. During hospitalization : 1 times, color : yellow, odor : tipically, tekstur : soft b. Urination Before hospitalization : 10 times / day drippings, color : yellow During hospitalization : using catheter 500cc, color : orange

4. Activity exercise pattern: Capability self - hygiene Eat / drink Bathing Toileting Dressing Mobilization on bed mobilization Ambulation / ROM Explanation : 0 : Independent 1 : Support Tools 2 : Assissted Others - Oxsigenasion: client using nasal canul 5. Sleep rest pattern: Before hospitalization : take a nap 2 hour, sleep 7 hour / day During hospitalization : take a nap 1 hour, sleep 6 hour / day 3 : Assissted Other And Tool 4 : Totally Depending 0 1 2 3 4

6. Perceptual pattern : During illness :

 Vision Hearing Tasting Smelling Sensasion

: client said blurred vision : client said hear chiming clock : client can taste sweet and salt : client can smell eucalyptus oil : client cal feel pain on genetalia, scale 4, intermittent and like stab of needle.

7. Self perception pattern a. Self image b. Self esteem c. Self Ideal d. Self role e. Self identity : client fell comfort with all his body although had : client had good relation wit his environment. : client hopes health so he can stay at home. : client as father : client is a male, married and has 6 childrens amputation on left leg.

8. Role relationship pattern Client cant met neighbor and can share story with them at home 9. Coping stress tolerance pattern Client never angry, just be patient with all situation. 10. Value believe pattern Client is religious people, he believe to God that he will get well soon and never hope to die, he always does pray fifth times / day. D. PHYSICAL EXAMINATION 1. General appearance 2. Consciousness 3. Vital Sign 4. Head Hair : composmentis : E4M6V5 = 15 : BP : 140 / 90 RR : 23 x/ minute : mesocephal : color : black and white, no dandruf, rare hair almost bald Eye Nose Ear : pupil isokor, conjugctiva : no anemis, sklera : no ikteric : clean no secret : clean no secret : no sprue, teeth loss 7 8 4 T HR : 37o C : 94 x/minute

5. Mouth

6. Neck 7. Thorax a. Lung

: no enlargement tyroid gland : symmetric :I Pal Per Aus : : : : : : : : : : : :

b. Hearth

:I Aus Pal Per

8. Abdomen

:I Aus Pal Per

9. Inguinal 10. Genital 11. Extremities

: no enlargement lymph gland : incision post op : 5 amputation 5 5

E. THERAPY PROGRAM

F. DIAGOSTIC PROGRAM Date examination Result Unit Reference

G. DATA ANALYSIS No. 1 Data Etiology Probleme Airway clearence

Pain

Deficit knowledge

H. NURSING DIAGNOSE 1.

2.

3.

I.
No

INTERVENTION
Nursing diagnose Goal & outcome Planning Rationale

No

Nursing diagnose

Goal & outcome

Planning

Rationale

No

Nursing diagnose

Goal & outcome

Planning

Rationale

J.

IMPLEMENTATION

DX Date / Time

Intervention

Response

Signature

III

December, 4
th

Nursing assessment

S : client share about the condition

Niinu

2012 / Observe condition.

client O: client cooperative answer all question client complaint dyspnea, pain in the wound, blurred vision. BP : 140 / 90 T : 37oC RR : 23 x/ minute HR : 94 x/ minute

08.30 am

II

09.00 am

Wound care

S : client fell comfort, still pain Niinu but intermittent O: the wound hadnt odor,

redness, and pus. I-II 09.30 am Injection drug IV S : client no complaint O : drug enter by IV I-II 12. 00 am Lunch S : client feel full O : client completed all diet I-II 01.00 am Take a nap S : client feel fresh O : client look calm I-II 02.30 pm Bathing S : client feel fresh O : client look clean I-II 03.00 pm Observe condition S : client said still little dyspnea O : BP : 140 / 80 mmHg T : 37oC RR : 22 x / minute HR : 90 x / minute I 04.00 pm Deep exercise II 04.15 pm Relaxation technique I-II 04.35 pm Dinner Oral drug breathing S : client said better O : client cooperative do exercise S : client said better O : client calm, do by self S : client feel full O : diet completed, drug enter by Annisa Annisa Annisa Annisa Annisa Niinu Niinu Niinu

of client, vital sign

oral I-II 05.00 pm Injection IV drug S : client no complaint O : drug enter by IV II 06.45 pm Create calm situation S : no complaint O: client look calm Savi Savi Annisa Annisa

K. EVALUASI Date / time December, 4 2012 / 02.00 pm December, 4th 2012 / 08.00 pm I II
th

Dx

Evaluasion

Signature

Goal is achived in part, continued intervention: I II - Deep breathing exercise - Relaxation technique Goal is achived in part, continued intervention: - Observe clients condition - Create comfort environment

Niinu

Annisa