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STIKES RS.

BAPTIS KEDIRI
NURSING PRODUCTION PROGRAM
MEDICAL NURSING SURGERY

STUDENT NAME : Widya Wati………………………………………………………………………….


NIM : 01.2.16.00563 ………………………………………………………………………
ROOM : Hemodialysis Room ……………………………………………………………....
DATE : 22 October 2019 ……………………………………………………………………

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.

3. CURRENT MEDICAL HISTORY


The patient said to come to Gambiran hospital at 15.00 to carry out the scheduled routine
hemodialysis, enter the hemodialysis room at 15.30 and finish hemodialysis at 21.05

4. PAST DISEASE HISTORY


The patient said 15 years ago had hypertension and 8 years ago was diagnosed with chronic kidney
failure and had to do hemodialysis

5. FAMILY HEALTH HISTORY


The patient said the family had hypertension from father and mother also had diabetes mellitus

6. SOCIAL AND SPIRITUAL PSYCHOLOGICAL HISTORY


The patient said that he often attended events in the RT or arisan in her RW area and did not pray 5
times each time
7. 7. DAILY ACTIVITIES PATTERNS
(Eating, resting, sleeping, eliminating, activity, cleaning and sexual)

No Activity daily living At home At hospital

1 Meeting the nutritional Eat and drink Eat and drink


and fluid needs Amount: Amount:
Type: Type:
1) Rice: ..... 1 ..... (portion) 1) Rice: ..... 1 ..... (portion)
2) Side dishes: there / no, 2) Side dishes: there / no,
Animal Animal
3) Vegetables: Yes 3) Vegetables: no
4) Drink: 600cc / day 4) Drink: 50 cc / day
Abstinence:- Abstinence:-
Eating / Drinking Difficulties: Eating / Drinking Difficulties:
Efforts to Overcome Efforts to Overcome
Difficulties: Difficulties:
2 Elimination pattern BAK: 2 x / day BAK- x / day
Amount: 50-100. Cc Amount: ............................
defecate: ccdefecate
Consistency: mushy Consistency:
Problems and how to solve:- Problems and how to solve:

3 Sleep rest patterns Afternoon: 1-2 Hours Afternoon:...... Hours


Evening - Hours Evening:.... Hours
Night: 4-5 Hours Night:........ Hours
Sleep Disorders: -- Sleep Disorders:--
Use of sleeping pills:-- Use of sleeping pills:--

4 Personal Hygiene 1. Bathing Frequency:- x / day 1. Bathing Frequency:-x / day


2. Hair washing frequency: 2. Hair washing frequency:
2x/week 3. Frequency of brushing your
3. Frequency of brushing your teeth:
teeth:2x/day 4. State of the nail:
4. State of the nail:2x/week 5. Change clothes:
5. Change clothes:2x/day
5 Other Activities Routine activities :- Routine activities :-
Activities undertaken at leisure: Activities undertaken at
watching television leisure: watching television

8. STATE / APPEARANCE / GENERAL IMPRESSION OF PATIENTS


The patient looks neat and clean

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

PATIENT NAME : Ny. S


AGE : 44 year old
NO. REGISTER : 299354

SOFT DATA PROBLEM LIKELY CAUSES


OBJECTIVE DATA
SUBJECTIVE 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

SD: The patient said nausea, loss of


appetite, and avoiding the
pungent odor, from the 2. Biochemical disorders 2. Nausea (00134)
morning not eating

OD: the patient appears to cover the


nose with a tissue that has been
spiked with wind oil, avoiding
food
LIST OF NURSING DIAGNOSIS
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354

NO DATE NURSING DIAGNOSES DATE SIGNATURE


APPEARED FINISHED
IMPLEMENTATION

October 22, Excess liquid volume is associated October 22, 2019


1 2019 with Regular mechanism
interference characterized by the
patient said weight increased in a
short time, stomach swollen and
legs swollen, swelling occurred the
day before hemodialysis treatment,
the patient looks swollen at the feet
and the abdomen is stomach
blood pressure: 190 / 100mmHg
BB: 52kg

Nausea relates to Biochemical


2 disorders marked by The patient October 22, 2019
October 22, said nausea, loss of appetite, and
2019 avoiding the pungent odor, from the
morning not eating, the patient
appears to cover the nose with a
tissue that has been spiked with
wind oil, avoiding food
NURSING PLAN
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354
Nursing diagnoses : Excess liquid volume is associated with Regular mechanism interference
1. NOC............................................................................................................ (Kode...............)

Maintained / enhanced on .....4......................


a. blood pressure 2
b. stable weight 2 Maintained / enhanced on ......4................

c. ascites 2 Maintained / enhanced on .......4....................

d. peripheral edema 2 Maintained / enhanced on .......4..................

e. ...................................................... Maintained / enhanced on ...........................

f. ...................................................... Maintained / enhanced on ...........................

g. ..................................................... Maintained / enhanced on ...........................

h. ..................................................... Maintained / enhanced on ...........................

i. ...................................................... Maintained / enhanced on ...........................

j. ...................................................... Maintained / enhanced on ...........................

k. ..................................................... Maintained / enhanced on ...........................

2. NOC............................................................................................................ (Kode...............)
a. ...................................................... Maintained / enhanced on ...........................

b. ..................................................... Maintained / enhanced on ...........................

c. ...................................................... Maintained / enhanced on ...........................

d. ..................................................... Maintained / enhanced on ...........................

e. ...................................................... Maintained / enhanced on ...........................

f. ...................................................... Maintained / enhanced on ...........................

g. ..................................................... Maintained / enhanced on ...........................

h. ..................................................... Maintained / enhanced on ...........................

i. ...................................................... Maintained / enhanced on ...........................

j. ...................................................... Maintained / enhanced on ...........................

k. ..................................................... Maintained / enhanced on ...........................


NURSING PLAN
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354
Nursing diagnoses : Nausea relates to Biochemical disorders
1. NOC: Nausea, vomiting, disturbing effect (Kode 2106.)
a. decreased fluid intake 2 Maintained / enhanced on 4

b. reduced food intake 2 Maintained / enhanced on 4

c. loss of appetite 2 Maintained / enhanced on 4

d. odor intolerance 2 Maintained / enhanced on 4

e. ...................................................... Maintained / enhanced on ...........................

f. ...................................................... Maintained / enhanced on ...........................

g. ..................................................... Maintained / enhanced on ...........................

h. ..................................................... Maintained / enhanced on ...........................

i. ...................................................... Maintained / enhanced on ...........................

j. ...................................................... Maintained / enhanced on ...........................

k. ..................................................... Maintained / enhanced on ...........................

2. NOC............................................................................................................ (Kode...............)
a. ...................................................... Maintained / enhanced on ...........................

b. ..................................................... Maintained / enhanced on ...........................

c. ...................................................... Maintained / enhanced on ...........................

d. ..................................................... Maintained / enhanced on ...........................

e. ...................................................... Maintained / enhanced on ...........................

f. ...................................................... Maintained / enhanced on ...........................

g. ..................................................... Maintained / enhanced on ...........................

h. ..................................................... Maintained / enhanced on ...........................

i. ...................................................... Maintained / enhanced on ...........................

j. ...................................................... Maintained / enhanced on ...........................

k. ..................................................... Maintained / enhanced on ...........................


NURSING PLAN
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354

NO NURSING DIAGNOSES INTERVENTION RATIONAL TTD

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

Hypovolemia Management (4170)


Hypovolemia Management (4170)
O: Monitor peripheral edema, Monitor intake output, Monitor
hemodynamic status, pulse, BP 1. In order to know the patient's condition
N: Limit sodium intake, weigh every day with the right time, 2. to find out body weight, and prepare
prepare the patient for dialysis patients for hemodialysis
E: instruct the patient and family to record intake and output as 3. so that families also take part in
needed supporting patient health
C: Collaboration with doctors in providing therapy 4. to provide appropriate therapy
NURSING PLAN
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354

NO NURSING DIAGNOSES INTERVENTION RATIONAL TTD

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

NO NO.DX Date / NURSING IMPLEMENTATION SIGN


Hour

1 1 October 1. Monitor peripheral edema (edema in the legs, ascites in


22, 2019 the stomach)
(17.00)
2. Monitor hemodynamic status (BP: 190 / 100mmHg,
pulse: 82x / minute)

3. Weigh the pre HD patient's weight (52kg)

4. Prepare the patient for hemodialysis (assistance)

2 2 October 1. Observe nonverbal signs of discomfort


22, 2019
(17.00) 2. Identifying factors that increase the occurrence of nausea
(food odor from other patients)

3. Provide understanding of nausea (nausea occurs due to a


buildup of urea, and nausea will disappear after the urea is
dialysis)

4. Make a complete assessment (frequency = frequent,


precipitating factors = pungent odor, food of other patients)

October 1. Monitor peripheral edema (multiple edema, no ascites)


3 1 22, 2019
(21.00) 2. Monitor hemodynamic status (BP: 180 / 100mmHg,
pulse: 80x / minute)

3. Weigh the weight of a post HD patient (50kg)

4. Tidy up the patient and the HD tools

1. Observe nonverbal signs of discomfort


October
4 2
22, 2019 2. Make a complete assessment of nausea (no nausea, smell
(21.00) nauseous food)
NOTES OF DEVELOPMENT
PATIENT NAME : Ny. S
AGE : 44 year old
NO. REGISTER : 299354

No No.DX HOUR EVALUATION


1 1 21:05 S: The patient said that the stomach had become smaller and swollen in the
legs with a lot of pain, and also lost 2 kg of body weight
O: The patient looks swollen in the legs and the stomach becomes smaller
BP: 180 / 100mmHg
Pulse: 80x / minute
A: The problem of excess fluid volume is resolved
P: The intervention was stopped

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