NURSIN

G
REPORT
Nama : Muhammad Norhidayat
Npm : 1614201110094
Kelas :VB
 ASSESSMENT

a. Patient identity
Name : Mrs. M
Age : 65 years old
Sex : Female
Religion : Islam
City/state : Banjar / Indonesia
Education : High School
Job :-
No.RM : 821386xxx
Medical Diagnosis : Hypoglycemia
Address : A. Yani Street Km .02 Banjarmasin

b. Responsible Identity
Name : Mr. Y
Sex : Male
Religion : Islam
Relationship : His biological child
Address : A. Yani Street Km .02 Banjarmasin
c. Main complaint
✗ The patient is weak and nervous.

d. Medical history
1. Current medical history
✗ Patient ny. M came to the emergency room at the Kebumen Hospital on October 31,
2018 at 10:30 a.m. I was ushered by his family with complaints of weakness,
shortness of breath, and decreased consciousness. Then the patient was taken to the
Dahlia Room. The patient is diagnosed by a doctor with hypoglycemia. When assess,
patients experience weakness, anemias, shortness of breath, and decreased
consciousness. With TTV: BP = 150/100 mmHg, P = 88x / min, T = 36.7˚C, RR = 30x /
minute.
2. Previous Medical History
✗ The patient was hospitalized because of anemia in 2016.
3. Family health history
✗ No patient's family has the same disease.
 e. Pattern of Meeting Virginia Henderson's Basic Needs

Oxygenation Pattern
✗ Before Pain: Patients often experience shortness of breath.
✗ When examined: Patients experience shortness of breath, spontaneous response,
irregular rhythm, RR 30x / minute.
Nutrition Pattern
✗ Before getting sick: patients eat rice 3 times a day.
✗ When assess: Patients eat 3 times a day with fine porridge but only spend half the
portion given.
Elimination Pattern
Urination
✗ Before Pain: Urination is not smooth, pain when urinating.
✗ When assess: the patient is attached to a catheter aid.
Defecate
✗ Before Sick: Defecate smoothly 1x a day, not diarrhea.
✗ When assess: Defecate smoothly 1x a day, no diarrhea, hard consistency, no pulp, back
pain when defecating.
Lanjutan..
Pattern of activity
✗ Before illness: Patients can act ...
✗ When assess: Patients only lie in bed, for mobilization assisted by nurses or family.

Break pattern
✗ Before illness: patients sleep regularly, 7-8 hours.
✗ When assess: the patient says he can't sleep well, sleep less 4-5 hours.

Spiritual Pattern
✗ Before getting sick: patients can perform prayer well.
✗ When assess: patients can only perform the prayer above bed in certain ways.

The need to communicate

✗ Before illness: patients can communicate well
✗ When assess: patients do not communicate well enough.
a. General examination
1. General Circumstances : Weak, nervous.
2. Awareness : Composmetic.
3. BP : 150/100 mmHg
4. P : 88 x / minute
5. T : 36.7 oC
6. R : 30 x / minute

b. Physical Examination (Inspection, Palpation, Percussion, Auscultation) includes function

if it is the senses :
1. Head : dull hair, dry scalp, no lesions, none bleeding.
2. Eyes : symmetrical, anemic conjunctiva, dry eyes.
3. Nose : symmetrical, no polyps, good smell, carrier function normal.
4. Ears : symmetrical shape, good hearing function.
5. Mouth : no tooth pain, no inflammation of the gums, dirty tongue, chapped
and dry lips.
6. Neck : no enlargement of the thyroid gland
Lanjutan….
7. Chest :
I = symmetrical form
A = normal heart sounds have a contraction of inspiration.
P = no tenderness
P = hypersonor (lung) sound.
8. Lungs : bronchovesicular breath sounds.
9. Heart : palpable heart rate, regular pulse rhythm, none swelling of the heart, sounds of
heart sounds II.
10. Abdomen :
I = no lesions
A = 20x / minute bowel sounds.
P = no tenderness
P = tympani
11. Integument : no lesions, no bleeding, no edema pale skin tone, elastic skin turgor.
12. Genetalia : no abnormalities, attached catheter aids.
13. Extremities :
✗ Above : physiological functions function normally
✗ Below : the physiological functions of the extremities function normally.
d. Laboratory Result

Blood Chemistry Results Normal Value

Blood sugar as 60 mg% 70 – 120

3. DATA ANALISYS
No. Data Etiology Problem
1. DS : The patient's family says the Poor sleep control Disturbed sleeping
patient cannot sleep at night, patterns
often wakes up since 3 days
yesterday tight, agitated and weak.

DO : Patients appear tight, weak,

restless, pale face, anemic
conjunctiva.
BP = 150/100 mmHg
P = 88 x / minute
R = 30 x / minute
T = 36,7˚ C
BS = 60 mg%
 NURSING
DIAGNOSIS
Disturbed
sleeping patterns
b.d poor sleep
control
 INTERVENTION
No Nursing Diagnosis Mean/Result Criteria Interventio Rational
1 Disturbed sleeping After nursing measures for 2 x a. Monitor patient's general condition a. Knowing consciousness, and the
patterns b.d poor 24 hours, the patient is and TTV condition of the body in normal
sleep control expected to be able to rest the b. Assess Sleep Patterns. or not.
optimal night's sleep with c. Assess the factors that cause sleep b. To find out the ease of sleep.
Result Criteria: disorders (pain, fear, stress, anxiety). c. To identify the actual cause of a
• Amount of sleep in normal d. Record action abilities to reduce sleep disorder.
limits 6-8 hours / day anxiety. d. To monitor how far you can be
• Sleep patterns, quality e. Create a comfortable atmosphere, calm and relaxed.
within normal limits. reduce or eliminate environmental e. To help relaxation during sleep.
• The face is not pale and distractions and sleep disorders. f. Makes it easy to get optimal
the conjunctiva of the eye f. Use sleep aids (eg warm water to sleep.
is not anemic because of compress muscle relaxation, g. To calm the mind from anxiety
lack of sleep. night. massage on the back, soft music, and reduce muscle tension
• Able to identify things that etc.). h. Medication according to the
improve sleep. g. Teach distraction relaxation. schedule.
h. Give medicine with doctor's
collaboration.
 IMPLEMENTATION
6.

No Day/ Date Time Diagnosis Implementation Evaluation Ttd

1 Thursday 09.00 a.m Disturbed sleeping a. Monitor patient's general S: the client said that he was
condition and TTV
6 Dec 2018 patterns b.d poor b. Assessing Sleep Patterns. able to sleep, but it was still
sleep control c. Assessing factors that cause easy to carry
sleep disorders (pain, anxiety,
immobility, foreign
environment, temperature). O: number of client sleep
d. Creating a comfortable
atmosphere, reduce or hours 4-6 hours
eliminate environmental BP =130/100 mmHg
distractions and sleep disorders.
e. Using sleep aids (eg warm P = 88 x / minute
water to compress muscle R = 27 x / minute
relaxation, reading material,
massage on the back, soft T = 36,7˚ C
music, etc.).
f. Teaching distraction relaxation.
g. Giving medication with doctor's A: the problem is partially
collaboration. resolved

P: maintain and continue

intervention
 EVALUATION
7. EVALUATION
No Day/Date Time Diagnosis Evaluation
1 Saturday, 09.00 a.m Disturbed sleeping S: the client said that he was able to sleep, but he still didn't feel
8 Dec 2018 patterns b.d poor well
sleep control O: number of client sleep hours 5-6 hours
BP = 130/100 mmHg
P = 88 x / minute
R = 26 x / minute
T = 36,7˚ C
A: the problem is partially resolved
P: maintain and continue intervention
a. Monitor patient's general condition and TTV
b. Assess Sleep Patterns.
c. Assess the factors that cause sleep disorders
d. Create a comfortable atmosphere, reduce or eliminate
environmental distractions and sleep disorders.
e. Use sleep aids (eg warm water to compress muscle relaxation,
reading material, massage on the back, soft music, etc.).
f. Teach distraction relaxation.
g. g. Give medicine with doctor's collaboration.
Thanks!

Any questions?

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