NURSING IN Ny.

D WITH helplessness RESPATI

(Review of Cases)
Ny. D age of 30 years came to the hospital RESPATI on 20 April 2018, with the client's
face was pale, when asked by the client only indifferent silence with a blank stare, clients
seemed to avoid eye contact with the nurse, and the client looks often take a deep breath.
The client's family says that the client has been diagnosed with diabetes mellitus one year
ago. This could make the client feel sad and ashamed so that the client can not accept the
disease makes treatment frustrating because the clients complex and because of the
inability of the client to perform any previous activity independently and must now be
assisted by the family. However, the client looks even more miserable and hopeless during
the past 1 month, the client also has been lackluster and indifferent will cure the disease
that do not heal.

A. assessment
I. Client identity
Name : Ny. D
Age : 30 years
Gender : Women
Education : High School
Work : Housewife
Religion : Islam
Tribes Sundanese / Indonesian
Marital status : Married
Address : Jl. Nologaten No. 23 A, Jember
Dates RS : 20 April 2018 10:30 pm Hours
No. CM : 098 765

II. Main complaint

A client of said client family is always silent, indifferent and frustrated by the
disease.

III. hospital sheet

 a. Disease History Now
At the time of the assessment on 21 April 2018 at 08.00 pm, the client's
face was pale, when asked by the client only indifferent silence with a blank
stare, clients seemed to avoid eye contact with the nurse, and the client looks
often take a deep breath.

b. Past medical history

Families of patients said that clients have been diagnosed with diabetes
mellitus one year ago. This could make the patient feel sad and ashamed so that
the patient can not accept his illness makes patients frustrated because
treatment is complicated and because the patient's inability to carry out
previous activities independently and must now be assisted by the family.
However, the client looks even more miserable and hopeless during the past 1
month, the patient also had lackluster and indifferent will cure the disease that
do not heal.

c. Family Disease History

The client's family said in a client family there are family members who
have a history of the disease, no history of hereditary diseases such as asthma,
diabetes mellitus, and no history of infectious diseases such as tuberculosis,
hepatitis and HIV / AIDS.

IV. Physical examination

a. General Situation
1. Awareness : Compos mentis
2. BB and TB : - Before the pain: 48 kg / 153 cm
- After the pain: 48 kg / 153 cm

3. Examination of vital signs

Blood pressure : 110/70 mmHg
Pulse : 82 x / minute
Respiration : 21 x / minute
Temperature : 36C
4. Assessment Head to Toe
a. Head
Oval head shape, scalp looks clean, no bumps, no tenderness, no scars
on the head.

b. Hair
Black hair color, hair texture bumpy, patchy hair deployment, client's
hair looked clean but a little greasy.

c. Eye
Rounded eye shape, white sclera, conjunctiva pallor, normal pupillary
reflexes evident when examined using light, the pupils shrink and swell
when the light turned away when the light is brought near.

d. Ear
Symmetrical shape, no wax, no lesions, no inflammation.

e. Nose
Symmetrical shape, no swelling, no lesion, no bleeding.

f. Mouth
Symmetrical shape, normal lip color looks brownish, mucous lips a bit
dry, no lesions, pink gums.

g. Neck
Symmetrical shape, there is no swelling of the thyroid gland, no
tenderness, good neck movement, swallowing reflex is good.

h. Chest
Shape symmetrical breasts, normal heart sounds, no additional noise in
the lungs (wheezing) and heart (murmur), chest expansion balanced,
normal breast, no tenderness.

i. abdomen
 Normal skin color, no lumps, no lesions, no scarring, abnormal
intestinal peristalsis (7 x / min).

j. genitalia
No tenderness, no lesions, no lumps, at the time of bowel and bladder
previously had no complaints.

k. extremity
- Above: The second form symmetrical hand, right hand inserted
infusion, strong hold prisoners, no lesions, no lumps, no tenderness.
- Below: The shape of the legs symmetrical, strong hold prisoners, no
lesions, no lumps, no tenderness.

V. psychosocial
When home clients stay at home, rarely do outside activities, even the client does
not work.

VI. Self concept

a. picture of yourself : The client sees himself is a woman who is less fortunate
b. Personal identity : The client says that he is a woman.
c. The role of self : client said that he was once a healthy person
d. ideal self : Better client says that he does not need medication
anymore because pemyakitnya also not heal.
e. Pride : Client said he was useless and hopeless

VII. Social Connections

Before ill and was taken to hospital client is a person who is not easily
discouraged. Social relations client with the environment is good, but after a sick
client appeared to retreat.

VIII. spiritual
 a. Values and beliefs : Client embraced Islam
b. Religious activities : First client is a figure who diligently worship but when
the client is still diligent worship sakitpun

IX. Mental Status

a. Appearance : The appearance of the client looks tired and desperate
b. Talks : Client indifferent and silent with a blank stare

X. natural feelings
Clients often take a deep breath, sad and frustrating disease in its natural
memikikan.

XI. During interaction

During interviews conducted client interviews difficult to respond, indifferent,
seen a lot of daydreaming and avoiding eye contact. Clients often silent with a
blank stare. Client perception feels that what happened to her is her fault.

XII. Thought process

a. Obsession: do not look any desire that is repeated by the client.
b. Phobia: clients feel fear can not be cured so that clients feel desperate

XIII. memory
Clients are not impaired long-term memory, short-term and current.

XIV. elimination of patients

1. CHAPTER
 Frequency : 1-2 x / day
 Complaint : No complaints during defecation
 Diarrhea : No diarrhea
2. BAK
 Frequency : uncertain
 color of urine : Yellow
  Complaint : No complaints when BAK

B. Data analysis
No. Data Nursing issues
1. DS: powerlessness
 Families of patients said that the patient had
been diagnosed with diabetes mellitus one
year ago
 The patient's family say the patient is unable
to move as before the illness independently
 Families of patients said patient activity
assisted by the family
 The patient's family says patients are
frustrated because treatment is complicated

DO:
 Patients appear to be disinterested and
indifferent to be the treatment of the disease
 Patients appear to suffer from the disease that
does not heal

C. Nursing diagnoses
powerlessness

D. Nursing interventions
Nursing Aim criteria Results Intervention Rational
diagnoses
powerlessnes General After the act of 1. Develop a 1. To make the
s purpose: nursing patients relationship of client feel safe
Patients are able are able to: mutual trust and
to think 1. Patients are comfortable
positively and able to 2. So that the
recognize and patient
reach a realistic express 2. Listen continues to
goal. emotions attentively reveal the
2. Patients are client contents of his
Special purpose: able to modify feelings
1. Patients can the negative 3. Help the 3. Help patients
build a cognitive patient to identify factors
trusting patterns identify the that lead to
relationship 3. Patients are factors that can powerlessness
2. Patients are able to lead to 4. Introduce the
able to participate in helplessness ability and
develop decision- 4. Identify the positive things
positive making capabilities possessed
expectations, 4. Patients are and positive patient
and controls able to be aspects which
the feeling of motivated to owned the
powerlessnes actively patient as well
s achieve as expanding 5. Help patients
3. Families realistic goals self-awareness assess their
were able to 5. Patients are 5. Help assess the existing
recognize the able to develop patient's ability capabilities
powerlessnes positive to do today
s of the expectations 6. Help the 6. Help patients
patient's 6. Patients are patient choose choose an
condition able to control the activities activity
4. The client is the feeling of that will be
able to powerlessness trained in
practice the accordance
7. Help train
techniques with the
activity to
they have patient's ability
patients
been taught 7. Train the
8. To help
selected
patients
activities
control their
feelings in
8. Help clients order to take
identify and further action
reduce feelings 9. To help
patients make
positive
expectations
10. To help
patients
9. Help the control the
patient feeling of
develop powerlessness
positive
expectations
benefits

10. Help the

patient to
control a
feeling of
powerlessness