NURSING CARE OF MRS.

A WITH NURSING PROBLEMS

POWERLESSNESS

I. ASSESSMENT

A. Patient Identity

1. Name : Mrs. L

2. DOB : March 7, 1975

3. Age : 44 years old

4. Sex : Female

5. Religion : Moslem

6. Marital Status : Married

7. Job : Housewife

8. Education : Junior High School

9. Ethnic : Sundanese

10. No. RM : 1500527

11. Address : Ardio Road, West Bogor, Bogor

12. Medical Diagnoses : Hyperglycemia

B. Responsible Identity

1. Name : Mr. Y

2. Age : 47 years old

3. Sex : Male

4. Religion : Moslem
 5. Job : Entrepreneur

6. Address : Ardio St, West Bogor, Bogor

7. Relationship with patient : Husband

C. Medical History

1. Main Problem

On March 11, 2019, Mrs. L, 44 years old, came to the emergency

room delivered by her husband with injuries on her right leg that

did not heal and spread. The client feels her health condition is

became worse and unable to perform daily activities.

2. Past Medical History

The client said She had been treated with the same complaint,

hyperglycemia.

3. Head to Toe Assessment

a. General state : Moderate

b. Consciousness level : Composmentis

c. Vital sign

1) Blood pressure : 150/90 mmhg

2) Pulse : 97 x/minute

3) Respiration : 22 x/minute

4) Temperature : 37,4 c
 d. Body weight : 72 kg

e. Body height : 157 cm

f. Extremities

There is a wound on the right leg, the wound spreads on the

area about 7 cm and 2 cm in depth, blackish, red color, there’s

pus and swelling around the wound. There are obstacles to

movement in the right foot.

D. Self Concept

1. Body Image

The client said she was not comfortable with the wounds on her leg.

2. Self Role

Client is a housewife and mother of 1 daughter.

3. Personal Identity

Client is a housewife. She limited her activity.

4. Self Ideal

Client hopes to recover from her illness.

5. Self-esteem

Client always leave it to the Almighty God.

E. Social Assessment

1. House condition
 The client said the condition of her house is not tidy and clean

because client said she rarely cleaned it because of her limited

activities.

2. Family

The client said there was no problems in her family. She lives with

her husband because her child is married.

3. Finance

The client said the financial source is from her husband's salary,

sometimes their child is also helping the family finance.

4. Spiritual

She is a moslem and always pray to the Almighty God

F. Mental Status Assessment

1. Appearance

The client's appearance is neat and clean. The client have an

overweight body.

2. Behavior

Before getting sick, the client is friendly to anyone. After entering

the hospital, the client becomes moody and she said that she unable

to do anything.

3. Talking
 When talking to a nurse, the client answers the question briefly, the

client voice volume is small, client talk slowly and the expression

on the client face is gloomy.

4. Nature of Feeling

The client feels her health condition is became worse and unable to

perform daily activities.

II. NURSING DIAGNOSES

Nursing diagnoses of this case is Powerlessness

III. INTERVENTION OF NURSING CARE

No. Nursing Purpose Intervention Rational

diagnoses

1. Powerlessness General 1. Build a trusting 1. The main key in

purpose: relationship. psychosocial nursing

The client care.

shows believe 2. Help patients to

that the client identify factors 2. Providing Patients can

can recover that can affect find out the cause of

from her powerlessness. powerlessness.

illness, 3. Discuss with the 3. opportunities for

patient a realistic clients to act in the

feel able to do choice in decision-making

something, treatment. process and increasing

feel able to patient self-

control the confidence.

source of 4. Involve clients in the

powerlessness. 4. Involve patients decision-making

in making process, increase self-

Specific decisions about confidence.

purpose: care routines or

Identify treatment plans. 5. Help patients to

actions that are 5. Help clients express her feelings

in control, identify life related to

express in situations that powerlessness.

words the cannot be

ability to take predictable.

the necessary

actions.

Express

adequate

support from

the closest
person, for

example

family.
NURSING CARE PLAN of Mrs.I with SLEEPING DISTURBANCE

Arragged to Fulfill One of The Task of Psychosocial English

Arraged bye:

Handini Eka Purnamasari P173203160

Mia Kurnia P17320316042

Class:

III-A

BANDUNG POLYTECHNIC OF HEALTH

BOGOR NURSING DEPARTEMENT
2019