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BAPTIS KEDIRI
NURSING PRODUCTION PROGRAM
MEDICAL NURSING SURGERY
1. BIODATA:
Name : Ms.S Reg. 299359
Age : 44 years old
Gender : Women
Religion : Islam
Address : Prambon Nganjuk
Education : High school
Occupation : Entrepreneur
MRS Date : 22 October 2019
Date of assessment : 22 October 2019
Blood group :B
Medical diagnosis : End Renal State Disease
2. MAIN COMPLAINT
Patient said that weight increased in a short time, the abdomen was enlarged and the legs were
swollen, swelling occurred before undergoing routine hemodialysis.
9. VITAL SIGN
Body Temperature : 36,5 ºC
Pulse : 82 x / minute
Blood Pressure : 190/100 mmHg
Respiration : 20 x / minute
TT / TB : 52 Kg, 170 cm
10. PHYSICAL EXAMINATION
A. Head and Neck Examination
Inspection: The patient's hair looks clean, the patient's conjunctiva is pale, the patient's mucosa looks
dry
Palpation: no thyroid enlargement and no neck pain
B. Integumentation of Skin and Nails:
Skin: patient's skin looks dry, brown, dull
palpation: swelling in the legs and abdomen
Nails: the patient's nails appear short and clean
C. Breast and Underarm Examination (If needed):
(not assesment)
D. Chest / Thorak examination
Thorax Inspection : normal chest shape, right and left chest retraction are the same, no loose appearance,
no scar / lesion
Lung: Palpation: right and left vocal fremitus are the same,
Percussion: Sonor / Resonan
Auscultation: vesicular breath sounds, no additional breath sounds
E. Heart Examination
Inspection : ictus cordis does not appear
Palpation : ictus cordis on ICS 5
Percussion : normal borderline
above: ICS 2
below: ICS 4
left: ICS 5 mid clavicula sinistra
right: ICS 4 mid clavicula dextra
Auscultation : Regular
F. Abdomen Examination
Inspection : symmetrical, no lesions, abdominal ascites
Auscultation : bowel sounds 12x / minute
Percussion : sounds tympanic
Palpation : no tenderness
G. Sex examination and surrounding area (if needed):
(not assesment)
H. Musculoskeletal examination
0 = no muscle contraction 5 5
1 = only muscle contractions (severe weakness)
2 = range of motion (passive ROM) 5 5
3 = active motion can defy gravity
4 = active movement, can only withstand some pressure
5 = active movement, can fight full resistance
I. Neurological examination
GCS 456
4 = can open eyes spontaneously
5 = good verbal orientation
6 = motor response following orders
J. Mental Status
Patient compositional awareness (fully conscious patient)
11. Medical Support Examination:
Date :22 october 2019
HbsAg : Negatif
SI : 102 mg/dl
TIBC : 347 mg/dl
12. Implementation / Therapy
Hemodialysis 2 times a week
QB: 200 ml QD: 500 ml Ultrafiltration: 2.5 liters
Drug: 10ml amplodipine 1x / day
150ml irbesartan 1x / day
13. Clients / Family expectations regarding the ailment:
The patient and family say they want to get well soon from their illness
ANALISA DATA
SD: the patient said weight 1. Regular mechanism interference 1. Excess liquid volume (00026)
increased in a short time,
stomach swollen and legs
swollen, swelling occurred the
day before hemodialysis
treatment
OD: the patient looks swollen at the
feet and the abdomen is ascytes
blood pressure: 190 /
100mmHg
BB: 52kg
2. NOC............................................................................................................ (Kode...............)
a. ...................................................... Maintained / enhanced on ...........................
2. NOC............................................................................................................ (Kode...............)
a. ...................................................... Maintained / enhanced on ...........................
1. Excess liquid volume is associated with Electrolyte monitor monitoring (2020) Electrolyte monitor monitoring (2020)
Regular mechanism interference
characterized by the patient said weight O: Monitor for signs and symptoms of hypernatrenia, Monitor 1. to be able to immediately deal with the
increased in a short time, stomach swollen for signs and symptoms of hyperkalemia problems being experienced by patients
and legs swollen, swelling occurred the day
N: Give the right diet to patients with electrolyte imbalances 2. So that complications in patients do not
before hemodialysis treatment, the patient
(potassium-rich foods and low-sodium diets) occur
looks swollen at the feet and the abdomen is
stomach E: Teach patients how to prevent and minimize electrolyte 3. so that families and patients are able to
blood pressure: 190 / 100mmHg imbalances take part in efforts to make patients
BB: 52kg healthy
C: Consult a doctor if signs and symptoms of fluid and
electrolyte imbalance persist or worsen 4. In order to get a solution to provide the
best intervention for patients
2. Nausea relates to Biochemical disorders Nausea Management (1450) Nausea Management (1450)
marked by The patient said nausea, loss of
O: Observation of non-verbal signs and discomfort 1. To be able to know what the patient is
appetite, and avoiding the pungent odor, experiencing even though the patient is
from the morning not eating, the patient N: Identify factors that can cause nausea arise, Give not talking
appears to cover the nose with a tissue that understanding of nausea, causes of nausea and duration of
has been spiked with wind oil, avoiding food nausea, Perform a complete assessment, frequency, 2. In order to be able to know what fartor is
duration, and triggers nausea. capable of increasing patient nausea
E: Teach patients to use non-pharmacological (relaxation) 3. So that patients are able to manage their
techniques nausea well
C: Collaboration with doctors providing therapy 4. So that patients are able to be treated and
given the best possible intervention
NURSING IMPLEMENTATION
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354
2 2 21:05 S: The patient said that he was not nauseous, it was normal to smell food
O: The patient looks fresher and does not avoid odors
A: Nausea problem resolved
P: Intervention terminated