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NURSING CARE OF MRS. A WITH NURSING PROBLEMS POWERLESSNESS I.

ASSESSMENT A. Patient Identity 1. Name

: Mrs. L

2. DOB

: March 7, 1975

3. Age

: 44 years old

4. Sex

: Female

5. Religion

: Moslem

6. Marital Status

: Married

7. Job

: Housewife

8. Education

: Junior High School

9. Ethnic

: Sundanese

10. No. RM

: 1500527

11. Address

: Ardio Road, West Bogor, Bogor

12. Medical Diagnoses

: Hyperglycemia

B. Responsible Identity 1. Name

: Mr. Y

2. Age

: 47 years old

3. Sex

: Male

4. Religion

: Moslem

5. Job

: Entrepreneur

6. Address

: Ardio St, West Bogor, Bogor

7. Relationship with patient

: Husband

C. Medical History 1. Main Problem On March 11, 2019, Mrs. L, 44 years old, came to the emergency room delivered by her husband with injuries on her right leg that did not heal and spread. The client feels her health condition is became worse and unable to perform daily activities. 2. Past Medical History The client said She had been treated with the same complaint, hyperglycemia. 3. Head to Toe Assessment a. General state

: Moderate

b. Consciousness level : Composmentis c. Vital sign 1) Blood pressure

: 150/90 mmhg

2) Pulse

: 97 x/minute

3) Respiration

: 22 x/minute

4) Temperature

: 37,4 c

d. Body weight

: 72 kg

e. Body height

: 157 cm

f. Extremities There is a wound on the right leg, the wound spreads on the area about 7 cm and 2 cm in depth, blackish, red color, there’s pus and swelling around the wound. There are obstacles to movement in the right foot. D. Self Concept 1. Body Image The client said she was not comfortable with the wounds on her leg. 2. Self Role Client is a housewife and mother of 1 daughter. 3. Personal Identity Client is a housewife. She limited her activity. 4. Self Ideal Client hopes to recover from her illness. 5. Self-esteem Client always leave it to the Almighty God. E. Social Assessment 1. House condition

The client said the condition of her house is not tidy and clean because client said she rarely cleaned it because of her limited activities. 2. Family The client said there was no problems in her family. She lives with her husband because her child is married. 3. Finance The client said the financial source is from her husband's salary, sometimes their child is also helping the family finance. 4. Spiritual She is a moslem and always pray to the Almighty God F. Mental Status Assessment 1. Appearance The client's appearance is neat and clean. The client have an overweight body. 2. Behavior Before getting sick, the client is friendly to anyone. After entering the hospital, the client becomes moody and she said that she unable to do anything. 3. Talking

When talking to a nurse, the client answers the question briefly, the client voice volume is small, client talk slowly and the expression on the client face is gloomy. 4. Nature of Feeling The client feels her health condition is became worse and unable to perform daily activities. II.

NURSING DIAGNOSES Nursing diagnoses of this case is Powerlessness

III. No.

INTERVENTION OF NURSING CARE Nursing

Purpose

Intervention

General

1. Build a trusting

Rational

diagnoses 1.

Powerlessness

purpose:

relationship.

The client

1. The main key in psychosocial nursing care.

shows believe

2. Help patients to

that the client

identify factors

can recover

that can affect

find out the cause of

from her

powerlessness.

powerlessness.

illness,

3. Discuss with the patient a realistic

2. Providing Patients can

3. opportunities for clients to act in the

feel able to do

choice in

decision-making

something,

treatment.

process and increasing

feel able to

patient self-

control the

confidence.

source of powerlessness.

4. Involve clients in the 4. Involve patients

decision-making

in making

process, increase self-

Specific

decisions about

confidence.

purpose:

care routines or

Identify

treatment plans.

actions that are

5. Help clients

5. Help patients to express her feelings

in control,

identify life

related to

express in

situations that

powerlessness.

words the

cannot be

ability to take

predictable.

the necessary actions. Express adequate support from the closest

person, for example family.

NURSING CARE PLAN of Mrs.I with SLEEPING DISTURBANCE Arragged to Fulfill One of The Task of Psychosocial English

Arraged bye: Handini Eka Purnamasari

P173203160

Mia Kurnia

P17320316042 Class: III-A

BANDUNG POLYTECHNIC OF HEALTH BOGOR NURSING DEPARTEMENT 2019