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A. REVIEW
Day/Date : Monday, July 1, 2019
Time : 14.15
By : Mrs. AM
1. PATIENT’S IDENTITY
a. Patient’s Identity
Name : Mr. S
Date of Birth : October 20, 1956
Sex : Female
Religion : Islam
Education : Primary School
Occupation : Entrepreneur
Race/Nationality : Javanese/Indonesian
Marital Status : Married
Address : Rejosari 05/03, Dawe, Kudus
Med Rec Number : 700XXX
Diagnosis Diabetes Mellitus
2. MEDICAL RECORD
a. Main Complaint
Feeling itchy
b. Heretofore medical record
The patient said she had felt itchy since before visiting the hospital and was begun by
vomiting. On June 25, 2019, the patient was sent off to Loekmono Hadi hospital,
Kudus. After arriving at ICU, she was treated by the concerning medical officer with
result TTV : TD : 190/110 mmHg, HR : 100 x/m RR : 20 x/m, T : 37.2, SpO2 : 99 and GDS
: 156 mg/dl. In the ICU, she was given a therapy through initial instruction of the
doctor and it was continued. Then, the medical diagnosis made them moved to be
inpatient in Melati 1 room.
c. Previous medical record
The patient admitted she ever suffered DM and HT
d. Family medical record
The patient’s family said not to have any medical record as suffered by the patient,
to suffer DM and HT.
e. Record of Diseases
The patient admitted to not have any medical, dietary, air, and other allergies.
3. Functional pattern
a. anthropometry : Tb = 155 cm
bb = 50kg
lila = 24,1 cm (N = > 23,5 cm)
imt = BB (kg)/TB2 (m) = 50/1,552
= 20,8 (N = 18,7 – 23,8)
BB ideal = 47,8 kg
b. Bio-chemical : June 27, 2019. 16.00 – 16.33 Western Regional Time
hb = 11,9 g/dl
gds=124
Creatinine = 0,58 mg/ds (N=0,5-1,2)
Sodium = 132,2 (N=135-145)
Calcium= 3,61 (N= 3,5-5)
C. Clinical sign: the skin turgor returns quickly, normal mouth mucosa, moderate pale, and no edema
D. Dietary: soft dietary, 3 times a day, eat ½ - 1 portion
Nursing Diagnosis
Increase familly
involvement
Encourage the
patient’s family
members to help in
developing a
nursing plan
Implementation
Subjective data: the patient family said to voluntarily assist in developing nursing plan.
Objective data: the patient family seemed voluntarily assist in developing nursing plan.
Subjective data: the patient said to voluntarily be given oral medicines included Metformin 500 mg.
Objective data: the patient drank the medicine voluntarily included Metformin 500 mg.
SD: the patient family voluntarily assisted in developing the further nursing plan.
OD: the family voluntarily assisted in the further plan.
SD: the patient was voluntarily given oral medicine included Metformin 500 mg.
OD: the patient voluntarily drank oral medicine included Metformin 500 mg.
SD: the patient voluntarily measured his weight and checked his blood level/GDS
OD: weight = 50.7 Kg, GDS = 110
... 13.15 3. Medicine management; Oral medicine provision included Metformin 500 mg.
SD: the patient said to voluntarily be given oral medicine included Metformin 500 mg.
OD: the patient was voluntarily given oral medicine included Metformin 500 mg.
Evaluation