Diabetes Militus.docx

I.

IDENTITY Name: Mr. W Male gender Age: 31 years old Address: Jl. Foundation No.22, RT.2 / RW.17, Kayu Putih. Entry Date: September 17, 2017 Date of Assessment: September 18, 2018 Islam Education: High School Job: Parking Lot No. RM: 78175

II. ANAMNESIS A. Main Complaints: foot tingling and numbness since 1 month ago accompanied by a feeling of weakness. B. Current Disease History Clients come to the eucalyptus KDK hospital on 11 September 2017 with complaints of tingling and numb feet since a month ago accompanied by a feeling of weakness. Feet often tingling, especially when after sitting cross-legged or squatting for a long time. Patients also claim that sometimes it doesn't hurt if their legs trip over objects. Patients also claim that they often complain of thirst, often feeling hungry and often nighttime BAK more than three times (not paying attention to how much urine comes out). C. Allergies (drugs, food, plaster, etc.) The patient says that the patient does not have a history of drug, food, and plaster allergies. D. Past Disease History The patient admitted that he had just completed his tuberculosis treatment since one and a half months ago and was declared cured by a doctor. E. History of Family Disease Mr. W has a history of the same disease in the form of diabetes, while there is no history of high blood pressure in the elderly. F. Habits / life style Families say that patients have smoking habits, and patients have the habit of drinking coffee with lots of sugar, patients also do not maintain the pattern or menu of foods and drinks consumed, snack foods that most patients enjoy are sweets. G. Medications used The family said that the patient had taken Tuberculosis medicine, and had not taken the drug since one and a half months ago. And since then patients have never taken other drugs. H. Nutritional / metabolic patterns a. Anthropometry Body weight before illness = 62 kg Current weight = 58 kg Height: 168 cm Body Mass Index = BB / (Tb (m) 2) = 58 / 2.82 = 20.5 Body Mass Index Category Underweight <18.5 Normal 18.5-24.9

Overweight> 25 Interpretation: based on the BMI formula, patients are in the normal category I.

Biomedical sign: Albumin: 3.54 g / dl; 2.64 g / dl; 2.27 g / dl Globulin: 2.55 g / dl; 2.85 g / dl; 3.46 g / dl Hemoglobin: 13.6 gr% When blood sugar: 333 mg / dl Fasting sugar: 256 mg / dl Normal blood glucose category: Fasting blood sugar: 80-99 mg / dl When blood sugar: 80-145 mg / dl Interpretation: In the lab results normal values are obtained for Albumin, Globulin, and Hemoglobin values, but when blood sugar and fasting blood sugar are high in abnormal limits. J. Pattern of elimination: a. BAK 1) Frequency: 1800cc / hour 2) Amount:> 1200-1500 cc / hour 3) Color: clear yellow 4) Odor: distinctive smell 5) Independence: independent / assisted b. feces 1) Frequency: 1x / day 2) Amount: normal 3) Color: yellow 4) Odor: distinctive smell 5) Character: shaped 6) Independence: independent / assisted Interpretation: The pattern of elimination experienced by the client is disrupted, because the stool and urine released are inappropriate or abnormal. K. Pattern of sleep and rest Duration: The client says sleep at 23.30 WIB - 04.00 WIB (four and a half hours) and during the day sleep for one hour. Interpretation: clients experience sleep disturbances due to anxiety. L. Cognitive and perceptual patterns Cognitive and Memory Functions: Able to communicate and be well-oriented when conducting studies. The client's vision is not functioning properly because of interference. Impaired vision that is felt is a rotating view and feels surrounding objects sway. Hearing, tasting and smell, clients function properly. Sensory, the client is still able to distinguish sharp and blunt sensory even if it must be with strong pressure. Interpretation: Patients experience interference with their vision.

M. Pattern of sexuality & reproduction The patient said he already had two children. The client said he never had a history of reproductive disorders. Interpretation: No problem N. System of values and beliefs The client said the client is Muslim and is always obedient in carrying out his prayer obligations even in bed

O. Coping and stress patterns The client says if there is a problem, it must be discussed with his family and closest relatives. The client resolves the problem with deliberation. The client looks anxious and stressed about the disease. III.

PHYSICAL EXAMINATION A. Examination of Vital Signs Pulse: 100x / minute, Respiration: 20x / minute, Blood Pressure: 120/80 mmHg, Temperature: 36.5 C GCS: E4V5M6 B. Head Examination Head Shape: Mesochepal, no deformity Hair: Black and not easily fall out C. Eye Examination Conjunctiva: The right and left eyes do not look anemic. Sklera: In the right and left eyes, jaundice is seen Pupil: right-left isocor, 3 mm diameter, light reflex (+ / +) Palpebra: No edema Visus: Good D. Nose Examination Shape: normal, no deformity Nasal lobe breath: none Secret: there is no nasal discharge

D. Mouth Examination Lips: Not cyanosis, not dry Tongue: Not dirty, the edge is not hyperemic Tonsils: Not enlarged Pharynx: Not hyperemic Tooth: Complete F. Ear Examination Shape: normal, no deformity Secret: none Functional: good hearing

E. Examination of the Neck JVP: not increase Thyroid gland: not enlarged Lymph nodes: not enlarged Trachea: there is no tracheal deviation F. Examination of thoracic 1. Lungs Inspection: left-right symmetrical, no retraction, no cuff. Palpation: left right fremitus vocal left Percussion: sonor in the entire lung field, hepatic lung limit at dextra SICV Auscultation: vesicular base sound, no additional sound in all lung fields 2. Heart Inspection: Ictus cordis is not visible Palpation: Ictus cordis is not palpable Percussion: Limit the heart Top right: SIC II LPS extra Bottom right: SIC IV LPS extra Top left: SIC II LMC sinitra Bottom left: SIST IV LMC left Auscultation: S1-S2, regular, no murmur, no gallop G. Abdomen examination Inspection: looks ascites, ciclery due to appendixitis surgery scars, Auscultation: normal peristalsis Percussion: screech in the right upper abdominal region to three fingers below the arcus rib and tympani in the lower right abdomen and left abdomen Palpation: supple, there is tenderness in the upper region, palpable enlargement of the liver and spleen is not palpable. The experimental test and the shift turn positive. H. Extremity Examination Superior: no deformity, no edema, good capillary perfusion, not anemic, warm akral. Inferior: no deformity, no edema, tip CRT more than three seconds, poor capillary perfusion, not anemic, cold akral. II. Data analysis data Subjective data : - Diabetics since eight months ago -clients complain of tingling feet and limp body -often urinating - clients like to eat coffee, eat sweet, smoke ten cigarettes a day Patients say they never exercise Objective data: - patients appear limp

Etiology Unhealthy lifestyle Beta cells in the pancreas are disrupted Insulin deficiency

Insulin retention

Hyperglycemia

problem Risk of instability in blood glucose levels

- Blood sugar time: 333 mg / dl -fasting blood sugar: 256 mg / dl -urine output:> 1500 cc / hour

Blood glucose levels are not controlled

Instability of blood glucose levels Subjective data : -Patients say the foot feels tingling and when tripping does not feel sick Objective data: - CRT end parts more than three seconds, poor capillary perfusion, cold feet, - TD: 120/80 - Pulse: 100x / minute - RR: 20x / minute - Temperature: 36.5 C

Blood glucose levels increase

Subjective data : -Client said that while at the hospital the client eats twice a day and only eats half the portion of approximately two tablespoons. -Patients say they feel nauseous and want to vomit

Decreased use of glucose by cells

Objective data: -Body weight before illness: 62 kg -Weight after illness: 58 kg -Height: 168 -Body Mass Index : 20.5

Ineffectiveness of Peripheral Tissue Perfusion

Insulin deficiency

Peripheral blood flow is impaired

Ineffectiveness of Peripheral Tissue Perfusion Disorders of nutrition fulfillment are less than the body's needs

Proteolysis

Amino acids increase

Gluconeugenesis

Ketogenesis Ketonemia

Decrease in BB

III.

Nursing diagnosis 1) The risk of instability in blood glucose levels is related to uncontrolled blood glucose levels. 2) peripheral blood, militus diabetes process. Ineffectiveness of Peripheral Tissue Perfusion is associated with decreased circulation 3) An imbalance in nutrition is less than the body's needs associated with less food intakes.

IV.

Interventions 1) The risk of instability in blood glucose levels is related to uncontrolled blood glucose levels. After nursing care is carried out, it is expected to instability normal blood glucose levels a) Monitor blood sugar levels, as indicated b) Monitor signs and symptoms of hyperglycemia: polyuria, polidipsi, polifagi, weakness, latergi, malaise, blurred vision or headache. c) Assess the patient's current and previous diet, including the foods he likes d) Provide examples of appropriate food menus e) Instruct patients and families regarding diabetes management f) Facilitate adherence to diet and exercise regimens 2) peripheral blood, militus diabetes process. Ineffectiveness of Peripheral Tissue Perfusion is associated with decreased circulation After nursing care is carried out, it is expected that ineffective perfusion of the patient's peripheral tissue can be reduced. a) Monitor skin and mucous membranes for areas of discoloration, bruising and rupture b) Place pads on the affected part of the body to protect the area c) Monitor blunt or sharp and hot and cold sensations (which the patient feels) d) Monitor the presence of Parasthesia appropriately e) Instruct patients and families to check the skin every day 3) An imbalance in nutrition is less than the body's needs associated with less food intakes. After nursing care is carried out, the patient's nutrition is expected to be fulfilled. a) Instruct patients about nutritional needs b) Determine the number of calories and types of nutrients needed by patients to meet nutritional needs c) Create an optimal environment when consuming food d) Monitor calories and patient food intake e) Monitor the tendency for an increase or decrease in body weight in patients