NAMA : ROSYIDA PUTRI QISMAWATI (010113a100)

ASUHAN KEPERAWATAN KELUARGA USIA PERTENGAHAN DENGAN HIPERTENSI

ANALISA DATA

DIAGNOSA

NIC

NOC

(NANDA)
Data Objektif:

Diagnosa

Keluarga mampu

Keluarga mampu

Tampak lemah,

keperawatan

mengenal masalah :

mengenal masalah:

TTV:

yaitu:

Level 1

Level 1

TD:160/100mmHg,

Domain 12:

Domain 2 :

Domain IV:

N : 100x/m,

kenyamanan

Physiological Complex

health knowledge &

S : 36,50C

Kelas

Level 2

behavior

1:kenyamanan

Kelas g :

Level 2

fisik

Elektrolyte and acid base

Kelas S:

(00134) mual

management.

Health knowledge

Level 3 ; Interventions

(1803) knowledge:

(2020) electrolyte

disease process

monitoring

(1805) knowledge: health

R: 20x/m
IMT = bb/tb2
45/1,652
16,6(kurang)
Bising usus
20x/m

- monitor for nausea ,

Data Subjektif:
a. Data individu
Pasien

vomiting, and diarrea

- monitor for fluid loss
and associated loss of

mengatakan

electrolite as appropriate

mual , muntah

- teach patient ways to

4x, mengalami

present or minizme

penurunan berat

electrolite imbalance

badan dua bulan

terakhir
b. Data Keluarga
1. Tidak tahu
cara
memodifikasi
lingkungan
yaitu pola
makan
keluarga
2. Keluarga
tidak tahu
tentang

behavior

pennyakit
(Tanda dan
gejala,
penyebab,dam
pak penyakit)
3. Keluarga
jarang
menggunakan
faskes
4. Keluarga
tidak dapat
merubah gaya
hidup
(makanan,
exercise)
5. Keluarga
menganggap
penyakit
sebagai hal
yang biasa
6. Keluarga
sering beli
obat sendiri
untuk
mengatasi
sakitnya
7. Keluarga
tidak tahu
cara
melibatkan
anggota
keluarga yang
lain untuk
mengatasi
masalah
8. Tidak ada care
provider dari
anggota
keluarga yang

lain
Keluarga mampu

Keluarga mampu

memutuskan:

memutuskan:

Level 1

Level 1

Domain 3: Behavioral

Domain IV: health

Level 2:

knowledge behavior

Kelas R : Coping

Level 2

assistance

Kelas Q: Health behavior

Level 3 : intervention

Level 3: outcomes

(5230) Coping

(1606) Participation in

enhancement

health decision

(5240) Counseling
- establish a therapeutik ,
relationship based on
trusht and respct
- determine how familyy
behaviour affectts patients
- assist patient to list and
prioritize all possible
alternative to a problem
Keluarga mampu

Keluarga mampu

merawat:

merawat:

Level 1

Level 1

Domain 1 :

Domain IV:

Physiological Basic

health knowledge &

Level 2

behavior

Kelas E :

Level 2

Physical basic promotion

Kelas S:

Level 3 ; Interventions

Health knowledge

(1450) neusea

(1821) knowledge

management

conceptions prevention

-enought patient to

Level 1

monitor own nausea

Domain II:

experience

Physiologic health

-encourage patient to

Level 2

learn straregis for

Kelas g:

managing own nausea

Fluid & electrolytes

- evaluate the impact of

Level 3 outcomes

nausea experience on

(0602) hydration

quality of life
-demonstrane acceptance
of nausea and collaborat
with the patient when
selecting a nausea control
energy
- teach the use of
nonpharmacological
techniques
- weight regukaryu
Keluarga mampu

Keluarga mampu

memodifikasi lingkungan:

memodifikasi lingkungan:

Level 1

Level 1

Domain 2 :

Domain V : Health

Physiological complex

Knowledge

Level 2

Level 2

Kelas K :

Kelas t :

Respiration management

Risk control & safety

Level 3 ; Interventions

Level 3 outcomes

(3200)aspiration

(1918) aspiration

precausen

precaution

- monitor level of
consciousness , caught

Level 2

reflex , geg reflex and

Kelas g:

swallowingb ability

Fluid & electrolytes

- maintain an airway

Level 3 outcomes

- request medication in

(0601) fluid balance

elixir form

(0602) hydration

Level 2
Kelas G
Medication electrolit and
acid-base management

Level 3 ; intervention
(2080) fruid/electrolid
management
-keep an accurate record
of intake and output
- monitor vital sign as
appropriate
- monitor for side effect
(nausea , vomiting )

Keluarga mampu

Keluarga mampu

memanfaatkan fasilitas

memanfaatkan fasilitas

kesehatan:

kesehatan:

Level 1

Level 1

Domain 6 : Health

Domain V : Perceived

System

Health

Level 2

Level 2

Class Y : Health System

Kelas EE : Satisfaction

Mediation

With Care

(7410) : Insurance

Level 3

authorization

Outcomes :

- explain reasons for

(3000) Client

obtaining preapproval for

Satisfaction: Acces to

health services or

Care Resources

equipment

(3003) Client

-explain consent for

Satisfaction: Continuity

laease of information

of Care

-obtain information and

(3009) Client

signature of patient or

Satisfaction:

responsible adult on

Psychological Care

assigment of benefits
form as needed
- collaborate with athore
health profesional about
continued need for health
services , as appropriate

Level 3 : Interventions
(7560) visitation
facilitation
- determine patient
preverences for visitation
and release of information
- consider legal ethical
implication regarding
pasien and family
visitation and information
rights
=determine need for
limited visitation, such as
too many visitors , patient
being impatient or tired ,
or physical status
- discuss family
understanding of patient
coindition