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

Arraged By : Siti Nurintan Sari

P17320316031

Ina Rumsyiani Ningsih

P17320316038

Class : III A

BANDUNG POLYTECHNIC of HEALTH BOGOR NURSING DEPARTEMENT 2019

NURSING CARE PLAN of Mrs.I with SLEEPING DISTURBANCE

A. Assesment 1. Identity a. Patient Identity 1) Name

: Mrs.I

2) Age

: 25 th

3) Sex

: Female

4) Religion

: Islam

5) Marital status

: Married

6) Job

: Housewife

7) Education

: Senior High School

8) Ethnic

: Sundanese

9) DOB

: 24-04-1994

10) No.RM

: 1400429

11) Entry Date

: 4/03/2019

12) Assesment Date

: 5/03/2019

13) Medical Diagnosis

: Dermatitis

14) Address

:Jl. Kampung Sawah blok D2 no 8

RT 07 RW 09 Kel. Bojong b. Responsible Identity 1) Name

: Mr.A

2) Age

: 26 th

3) Sex

: Male

4) Religion

: Islam

5) Job

: Private Officier

6) Address

: Jl. Kampung Sawah blok D2 no 8

RT 07 RW 09 Kel. Bojong 7) Relationship with patient : Husband

2. Major Complaints The client said it’s difficult to sleep because it’s itchy all over the body. 3. Current History of Illness The client entered an emergency room on March 4th 2019 at 10.30 pm, with a complaint of intense hives and signs of bruishing. The client said the itch he suffered was repeated over and over and would usually leave a mark that stood out. The client says an itch on the skin area may spread. The client says the itches which suffer are intense itchy which may disrupt a client’s activity. The client has filed a complaint from 3 weeks ago. 4. Past History of Illness The client has been in a Arga Makmur Hhospital with complaints of shortness of breath, and cough for a week. 5. Family History of Illness The client said his father had suffered from the same disease, and his father sufferes from shortness of breath too. 6. Psychosocial History The client said that he’s anxious because his itches not gone and afraid of complications. 7. Drug Use History The client says to cure his itc, he takes amoxicilin medication, and then he doesn’t feel itchy anymore 8. Daily Activity Before Hospitalization After Hospitalization Nutrition

The client says eat The client says eat twice a day. He lose three times a day. The his appetite because client he

eats

only

a

have

trouble quarter of the food,

swallowing

because the client has a nausea and trouble

swallowing Elimination

The client says pee the client says pee three times a day, the three times a day, the colour thick yellow. colour thick yellow. And the client says And hasn’t defecate defecate once times a yet day.

Activity/Sport

The client said never The client waas just exercised

Sleep Patterns

lying in bed

The client says sleep The client says sleep at 00.00 and wake up at 00.00 and wake up at 03.00 a.m. the client at

03.00

says it’s difficult to client sleep because the itch. difficult

a.m. says to

the it’s sleep

The client sleeps for 3 because the itch. The hours. And the client client sleeps for 3 never at take a nap.

hours. And then when wake up the client’s are not feeling so fresh. And the client never take a nap.

9. Head to Toe Assesment a. General State

: Moderate

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

: 140/90 mmHg

Pulse

: 98x/minutes

Respiration

: 22x/minutes

Temperature

: 370C

d. Weight gain

: 65 kg

e. Height

: 170 cm

f. Skin

: it’s got rubor (redness), it’s got bula

(scald), it’s got pain tap, it’s got edema (swellling)

B. Nursing Diagnosis Sleeping disturbance related to pruritus

C. Nursing Care Plan Nursing Diagnosis

Purpose

Outcomes

Sleeping

General :

disturbance related

Client

to pruritus

sleeping disturbance

Client

Spesific :

sleeping

Client pruritus

not

not

After

the

Intervention

Rational

treatment

suffer 2x24 hours we expect : not

suffer

disturbance,

suffer client not suffer any execessive stimulation (itchy) with outcomes : 1. Client not suffer sleeping (sleep

1. Help the patient move in an orderly

disturbance patterns

1.Exercise has a beneficial effect on sleep if carried out in the

are

evening.

good) 2. Bedtime is adequate

2.

Keep the bedroom still has good 2. The dry air makes the skiin ventilation and moisture

itch. A comfortable environment increases relaxation.

3. Quality sleep good

3. Prevent and heal the dry skin.

3.

Nocturnal

pruritus

disturbances normal sleep 4. Vital sign within normal boundaries

4. Encourage the client

to

avoid 4. Caffein has a peak effect 2-4

caffeinated beverages before on hours after consumption going to bed at night 5. Monitor vital sign of client (blood pressure, temperature)

pulse,

respiration,

5.

Find

out

the

general

circumstances of the client