Nursing care for Mrs.

E with Ansietas on
Sari Rejo Village, Medan Polonia District

I. PATIENT IDENTITY
Name : Ny. E
Gender : Female
Age : 50 years old
Marital Status : Married
Region : Islam
Education : Elementary School
Job : Housewife
Address : Sari Rejo Village, Medan Polonia Subdistrict.
Date of Assessment : March 10, 2018

II. MAIN COMPLAINT

At the time of review, Mrs. E said that she was very anxious and afraid of her
condition, the client said she felt nervous, unable to sleep, the patient also said that the
pain was in the head.

III. HISTORY OF HEALTH NOW

History Hypertension is known for 5 years can trigger the occurrence of stroke
experienced by Ny. E. Ny. E said pain in the head. Mrs. E was very worried about the
situation, the client said she could not sleep, her feelings were always restless. The
client said that the pain in his back, the pain did not spread and the pain was very
disturbing to the client activity.

IV. PAST HISTORY OF HEALTH

a) Disease that has been experienced
Ny.E said that Mrs. E's family had hypertension.
b) Treatment / actions taken
Mrs. E. Said she had been treated at the hospital.
c) Have been treated / operated
The family said Mrs. E had received medical treatment before at Marta Friska
Hospital in Medan.

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 d) Length of stay
The family said Mrs. E had been treated for 1 week at the hospital. Marta Friska
Medan.
e) Allergies
Mrs. E said she had no allergic history.
f) Immunization
The client said she did not remember her immunization history.

V. HISTORY OF FAMILY HEALTH

a. Parents
Mrs. E has a history of hypertensive hereditary disease
b. Siblings
Sister E also has a history of hypertension.
c. Existing hereditary disease
Mrs. E said she had hereditary diseases, namely hypertension.
d. Family members who died
Ny.E said the parents of the client had long since died.
e. Cause of death
Mrs. E said the cause of her parents died of hypertension.

VI. HISTORY OF PSYCHOSOCIAL CONDITIONS

a. Client's perception of the disease
The client said the conditions felt at this time were very disturbing to her activities.

b. Self concept
- Self-image
Ny.E said she liked all parts of her body.
- Ideal self
Ny.E has the willingness to recover and can move as usual.
- Pride
Ny.E feels cared for by her husband.
- Role of Self
Ny. E plays a wife and mother for their children
- Personal identity

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 During illness, most of the client's activities are assisted by her husband.

c. Emotional state
Clients sometimes cannot hold back their emotions.

d. Social relations
1. People who mean : people who mean to clients are children and their husbands.
2. Relationships with family: good client relationships with family.
3. Relationships with others: the client relationship with other people, the
neighbors are quite good
4. Obstacles in dealing with others : there are no obstacles in relating

e. Spiritual
1. Values and beliefs : clients are Muslim and in their daily lives clients carry out
activities according to the religious teachings of their beliefs.
2. Worship activities: the client performs worship according to her teachings and
beliefs by performing prayers 5 times a day and night.

VII. MENTAL STATUS

1. Level of awareness : Compos mentis
2. Appearance : Ny.E looks neat
3. Discussion : Ny.E speaks slowly
4. Nature feeling : Sad
5. Affect : Stable
6. Interaction during interviews : During Ny.E's eye contact interview enough.

VIII. PHYSICAL EXAMINATION

A. General Condition
Compos mentis
1. Vital sign
- Body temperature : 36.5 ° C
- Blood pressure : 150/100 mmHg
- Pulse : 76x / minute
- Breathing : 24x / minute

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 - Pain scale : 4 (1-10)
- TB : 153 cm
- BB : 47 kg

2. Head to toe check

- Head and hair shape : symmetrical and ovale
- Font : right in the middle and not there is a lump
- Scalp : clean with no irritation
- Hair : Spread and condition of hair grows evenly and the condition of hair is
clean. Ny.E scalp does not smells, scalp clean, no irritation
- Face skin color is brown. Face structure is oval and symmetrical
- Eye : Both eyeballs have a size that is same. Palpebral is pink and moist.
Conjunctiva and sclera is pink and sclera white. Pupil isokor. Cornea and iris
is clear. Visus Mrs. E is still capable see a distance of 100 meters. Good eye
pressure can be moved left and right.
- Nose : Symmetrical nasal bones and septumn position at the middle. Normal
nostrils, clean and non-existent blockage, left symmetrical and right. No
breathing using lobes nose.
- Ear : Normal ear shape symmetrical left and right, normal ear size, ear hole is
patent earpiece and clean, sharpness of hearing is Ny. E can hear with
distance 100 meters.
- Mouth and pharynx : Dry lip mucosa, Ny's teeth and gums looked well
maintained with good and clean, the tongue is clean and not there is an
abnormality, there is no udema in the oropharynx Mrs. E.
- Neck : Tracheal position is medial position. None swollen glands thyroid.
Voice that Mrs. E is able to speak well. Lymph nodes is Normal and none
signs of edem. Jugular veins is Existing and palpable. Carotid pulse is There
and palpable.
- Integument check : skin looks clean, Integumentary skin feels cold if
touched, brown skin color mature, clean and turgor skin no edema, good skin
moisture, no abnormalities in skin, skin looked clean.
- Musculoskeletal / extremity examination (symmetry, muscle strength,
edema) : Muscles appear symmetrical, no edema. Client's motor function
runs slowly

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 - Sensory function (touch identification, blunt sharp test, heat : Clients can feel
touch, vibration, heat, cold, and sharp, Gathering.

IX. DAILY PATTERNS OF HABITS

A. Eating and drinking patterns
1. Frequency of meal / day : regular clients eat 3 times a day
2. Lust / appetite : Lust for clients decreases
3. Heartburn : heart burn in Ny.E no
4. Allergi : Ny.E has no allergic history
5. Nausea and vomiting : the client does not nausea and vomit
6. Time of feeding : morning (8 o'clock), noon (13 o'clock), night (19 o'clock)
7. Amount and type of meal : only 3 table spoons
8. Time of administration of fluids / drinking : the time of administration of luids
cannot be determined when Ny.E is given depending on when feeling thirsty.
9. Problems eating and drinking (difficulty swallowing, chewing): Ny.E does not
have problems or difficulties in swallowing and in chewing food clients do not
have problems.

B. Personal hygiene
1. Body hygiene : Ny.E looks clean and neat.
2. Hygiene of teeth and mouth : clean mouth of clients diligently cleaning
3. Toenails and hands : Ny.E's toenails and hands look clean

C. Pattern of activities / activities

1. Description of the client's activities for bathing, eating, eliminating, changing
clothes is done independently, in part or in total : Ny.E can carry out her
activities independently.
2. Description of client worship activities during illness : During the treatment
period clients appear to carry out prayer and prayer activities.

D. Pattern of elimination
1. BAB
 BAB Pattern : 1-2 times / day

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  Stool character : soft
 History of bleeding : no history bleeding
 Diarrhea : no diarrhea
2. BAK
 BAK pattern : erratic
 Urine character : distinctive yellow smell
 Pain / burning / difficulty BAK : no difficulties BAK
 History of kidney disease / urinary fluid : no history Kidney illness/ bladder
 Efforts to overcome the problem : Take medication

E. Coping mechanism
When there is a problem the client sometimes harbors the problem if we don't first
tell the story.

X. Data analysis
Analyze nursing care data for Mrs. E with priority issues in Sari Rejo Village,
Medan Polonia.

Nursing
No Data
problems
1. Subjective data :
 The client said she was very worried about her
current condition.
 The client said she felt anxious
 Clients say she often urinate.

Objective data: Anxiety

 The client looks nervous
 The client looks pale and sweating through out the
body
 Client often go back and forth
 TD : 150 / 100mmHg, Pulse : 90x/ minute, RR :
23x/minute , temperature : 37.4oC

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  Clients often ask nurses regarding her condition

XI. Nursing Diagnoses

Anxiety

XII. Nursing Intervention

Diagnoses Goals Out Come Intervention Rational

Anxiety General purpose : 1. Control 1. Use a calming 1. Fostering
Client will reduce anxiety approach trust with client
anxiety from panic to 2. Coping 2. Calm the client 2. Helps relax
mild level mechanism feelings client
3. Try to 3. Giving
Special purpose : With the understand the comfort to
Client are able to: following situation client client
1. Fostering conditions (scale 4. Give 4. Increase
trusting 1-5: never, information about client
relationship rarely, diagnosis, Knowledge
2. Doing daily sometimes, prognosis and
activities often, always) action
3. Express and Indicator: 5. Assess anxiety 5. Know the
identify 1. Demonstrate and reaction rates level of client
her/his role flexibility physical at the anxiety
anxiety 2. Family shows level of anxiety.
4. Improve the flexibility of 6. Use approach 6. Fostering
physical the role of its and touch mutual trust to
health and members clients and
well-being 3. Involving nurses
5. Client are family members 7. Accompany 7. To reduce the
proctected in making client to support fear of clients
from danger decisions security and fear
4. Express 8. Instruct client 8. Increase

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feelings and capabilities to use patient
emotional techniques Knowledge to
freedom relaxation of deep Intervene
5. Indicates a breath, distraction independent if
reduction and 5 finger anxiety occurs
strategy anxiety hypnosis
9. Do back/ neck 9. Provides
rub comfort
10. Support 10. Involving
family family help
involvement in reduce anxiety
the right way