Nama : M.Nur Hidayatullah

NIM : 11.040

RESUME

Nursing care in Tn. S with Diabetes Mellitus

Name : Tn. S

Age : 57 Th

Address : Pacitan

education : SLTP

Job : Swasta

No. Reg : 103067

Dx. Medis : Diabetes Mellitus

Date of Assessment : 03 November 2011 Time 11.00 am

subjective:

Clients say fatigue, frequent urinating at night, thirst, and frequent sleepiness.

objective:

o Client looks sleepy

o Mucosal dry lips

o GDS: 230 mg / dl

o TTV: BP: 110/90 mmHg

N: 88 x / min

S: 36.6 0 C

RR: 24 x / min

B1 (Breath)- Chest symmetric- No nostril breathing- Regular breathing rhythm- Not installed 02

B2 (Blood)- Heart sound s1, s2 single- No additional noise- No noise

B3 ( Brain)- Awareness: composmentis- GCS: 4-5-6

B4 ( Bladder)- The color yellow is rather concentrated urine- Not attached catheter

Assasement:

1. Disorders of fluid balance and is associated with increased osmolarity electolyte secondary to hyperglycemia

2. Break the pattern of sleep disturbances associated with gangrene of the leg wound

3. Changes in nutrition less than body requirements related to insulin insufficiency

Planning:

- Disorders of fluid balance and is associated with increased osmolarity electolyte secondary to hyperglycemia

Plan of Action:

1. Observation and record vital signs every 4 hours

R /: Knowing the early occurrence of wound infection

2. Give fluids at least 2500 cc / hr

R /: Maintaining hydration and circulation volume.

3. Measure BB every day

R /: Preventing the spread and limit the spread of infection or cross contamination widespread

4. Monitor and record the input and expenditure BJ Urine

R /: Provides forecasts the need for fluid replacement, renal function, and the effectiveness of a given therapy

5. Note things such as nausea, abdominal pain, vomiting, gastric distention

R /: Lack of fluid and electrolyte alter gastrointestinal motility, which will often cause vomiting and potentially will lead to lack of fluids or electrolytes

Implementation:

1. Observe and record vital signs every 4 hours

2. Giving fluids at least 2500 cc / hr

3. Measure BB every day

4. Monitor and record the input and expenditure BJ Urine

5. Record things like nausea, abdominal pain, vomiting, gastric distention

evaluation:

subjective:

Clients say his body has not limp anymore

objective:

TTV: BP: 110/90 mmHg

N: 88 x / min

S: 36.6 0 C

RR: 88 x / mnt:

Bibliography

Wartonah and tarwoto. , 2006. Basic human needs and the nursing process 3rd edition. Jakarta: Salemba Medika

Carpenito, Lynda Juall.2007.Buku pocket keperawatan.Jakarta diagnosis: EGC

Doengos, Marlyn E.1999. Nursing Care Plan for Issue 3. Jakarta: EGC