TUGAS BAHASA INGGIS 2

NURSING DIAGNOSIS

NAMA KELOMPOK :

1. REKA SOPIYANTI (P07120317028)

2. RIA ELVIANA SUKMA DEWI (P07120317029)

3. SILVIA RISMAWATI (P07120317030)

4. SITI MARYAM AL-JANNATIN (P07120317031)

 NURSING CARE IN Mr. A

WITH THE MEDICAL DIAGNOSIS OF KIDNEY FAILURE

IN ROOM IRNA III C PUBLIC HOSPITAL IN MATARAM CITY

21 SEPTEMBER 2020

I. ASSESSMENT
Date of Entry: 21 September 2020
Entry Hours: 09.00 am
Date of Assessment: 21 September 2020
Study Hours: 9:45 a.m.
Room: -
Room No: -
Hospital: KOTA MATARAM Hospital
No. RM:
Medical Diagnosis: KIDNEY FAILURE

A. BIOGRAPHIC DATA
1. Client Identity
a. Name: Mr. A.
b. Age: 4 7 years
c. Male gender
d. Islam
e. Occupation: farming
f. Tribe / Nation: Sasak / Indonesia
g. Marital Status: married
h. Address: Jeruwaru
 2. Identity of Person in Charge
a. Name: Mrs. B
b. Age: 30 years
c. Female gender
d. Islam
e. Occupation: teacher
f. Tribe / Nation: Sasak / Indonesia
g. Marital Status: married
h. Address: jeruwaru
i. Relationship with Patient: Patient's Wife

A. HISTORY OF HEALTH
1. Main Complaints for Hospitalization
Client says limp
2. Complaints when being reviewed
The client said that she was weak, swollen in her right leg, and itching all over her
body since 2 days ago
3. Current Disease History
Two days before the client experienced swelling in the right leg accompanied by
itching all over his body, finally the patient's family brought the patient to the KOTA
MATARAM Hospital
4. Previous Disease History
Previous clients have never experienced a disease like now
5. Family History of Disease
The client said there was no family history of illness
6. Environmental Health History
The client said that they keep the environment clean
B. BIO-PSYCHO-SOCIAL-SPIRITUAL NEEDS
1. Perception pattern and healthy life management
a. Before getting sick
The client said the client had never been hospitalized before. When Sick
the client does not know the cause of the disease. Previously, the client
had never been taken for treatment anywhere
2. Nutritional Patterns
a. Before hurts
client says client's appetite is good. The daily food menu is rice, fish and
vegetables. Frequency 3x / day. Type of drink: ± 1500 cc of water.
and clients say they often consume colored drinks.
b. When Sick
The client said that the client's appetite for eating and drinking is like when he is
not sick.
3. Elimination Pattern
a. Before getting sick
client says CHAPTER ± 1x / 1 - 2 days, consistency is mushy. BAK ± 5x / day.
b. When Sick
client says CHAPTER 1 time a day with a soft consistency, yellow color & BAK
changes occur, namely in one day only 2-4 times (400-600 / day)
4. Sleep Rest Patterns
a. Before getting sick
Clients sleep for approximately 8 hours / day and take a 3 hour nap. Clients do
not have the habit before bed and after sleep.
b. When sick
Clients sleep approximately 6 hours / day with frequent waking and 2 hours of
naps. Because I was bored with the hospital atmosphere, and sometimes there
were many visitors.
5. Patterns of Activity and Exercise
a. Before getting sick
The client said that he works as a farmer, the client does sports walking in the
neighborhood once a week and gets tired easily after activities.
b. When Sick
While being treated, the client's activity is disturbed because he is not familiar
with the atmosphere of the hospital and the client wants to go home
immediately, the client's feet feel heavy if they are to walk.

6. Patterns of Relationships and Roles

a. Before getting sick
The client lives with his wife and lives well among his family members.
b. When Sick
Clients do not have problems in the pattern of peer relationships.
7. Cognitive Patterns and Perception
a. Before getting sick
The client does not experience sensory disturbances
b. When Sick
There is no change in cognitive perception patterns
8. Perceptual patterns and self-concept
a. Before hurts
The client acts as the husband in the family and earns a living, and works for his
wife
When it hurts
There is no change in self-perception patterns
9. Sexual and reproductive patterns
Not reviewed
 10. Stress and Coping Mechanism Patterns
a. Before getting sick
clients are always looking for a way out when there is a problem
When it hurts
the client is anxious about his condition when he is sick. the client looked
worried about his condition.

11. Patterns of Values and Beliefs

The patient is Muslim

A. PHYSICAL EXAMINATION
1. Generalist Status Check
General Condition: Good
Awareness: compos mentis
GCS: E4V5M6
TTV
- TD: 190/90 mmHg
- Pulse / Heart Rate: 190x / minute
- Respiration Rate: 24x / minute
- Temperature: 36ºC

1. Head to Toes Check

N
Parts of body Inspection Palpation Percussion Auscultation
O
1 - evenly - no lumps
Head spread hair - no edema
- black hair - no tenderness
 color -
- round head
-
shape
- no lesions
-
2 - looked - no swelling
Face worried - no tenderness
- -
-

3 Eye - - the
- - symmetrical
conjunctiva is eyes
not anemic - - no bumps
- -

4 no visible - no palpable
Nose secretions lesions
- - no tenderness

5 Mouth - The lip - no visible

mucosa looks lesions
moist - no tenderness
- The lip color
- - no lumps
is moist

6 Ear - looks - no lesions

 symmetrical - no tenderness
- looks clean - no lumps

7 Neck - no jugular - no lesions -

vein swelling no
enlargement of
the thyroid
gland

8 Thorax symmetrical - no tenderness - - normal single

shape - heart sound s1 s2 heart
- - symmetrical - sonor lung deafening sound
expansion of sound - vesicular
the chest lung sound
-

9 Abdomen - even skin - no tenderness - Bowel

tone - no lumps sounds 16
- symmetrical times / minute
shape -
10 Ekstermitas - even skin
On tone
- no edema
- no IV line

- even skin
tone
Ekstermitas - swelling in
Under the right leg

11 Genitalia - no
distraction
-
 B. TERAPI PEMBERIAN OBAT

N Nama Rute Dosis Uses

o
1 Amlodipine Iv 10gr Treat complaints in the form of
high blood pressure.

2 Lasix Iv 10gr Medicines used to treat fluid

buildup due to heart failure,
liver scarring or kidney failure.

3 Ondancentro Iv 10gr. To prevent and treat nausea and

n vomiting that can be caused by
chemotherapy, radiotherapy or
surgery
4

II. NURSING DIAGNOSIS

Name: Mr. A
. No. RM: -
Age: 47 years old
Diagnosis Medical: Kidney Failure
A. Data Analysis

N Day / Date Data Etiologi Problem

o
1 21 DS: Inability of the kidneys Excess fluid
September the client said the to secrete water and volume
2020 swelling in the right leg sodium
and leg felt heavy when
carried on the road.
DO:
• Dry and pale skin
• Edem in the right leg
+1 guard
• Fluid supply: intake
1600 - (2100 +690)
= +900 ml / day (output
+ IWL)
• Ureum: 134 mg / dl
• Creatinine: 3.1 mg / dl
• GFR: 19%
• Weight loss of 3 kg
from 50> 47 kg
TD: 190 / 90mmHg

2 21 DS: Nausea, vomiting and Nutritional

September The client said that the tight diarrhea imbalance: less
2020 stomach was bloated, than the body's
the body has been weak needs
for 2 days, canker sores
and weight have
decreased by 3 kg in
the last 3 months. DO:
• The client is sick
• A meal that is
consumed is only 1 P
• The client looks limp
• Urine within 24 hours
600cc
: BB: 47kg, TB: 150cm,
BMI: 22 (over weight)
Ideal client weight: 45
kg - 55 kg.
B.: HB: 12.0 g / dl HT:
L 29% Ureum: 134
mg / dl Creatinine: H
3.1 mg / dl
C.: ananemic
conjunctiva, abdominal
bloating, bowel sounds
18x / minute.
D.: the client's diet
3 times / day, clients
like, clients do not
really like drinking
water, diet low in
protein 40gr, low salt
 40gr.

B. Nursing Diagnosis Formulas

1.Excess fluid volume related to the inability of the kidneys to secrete water and
sodium is indicated by:
DS:
the client said the swelling in the right leg and leg felt heavy when carried on the
road.
DO:
•Dry skin

• Edem on the legs and feet

• grade +1
• Fluid balance: intake 1600 - (2100 + 690) = +900 ml / day (output + IWL)
• Ureum: 134 mg / dl
• Creatinine: 3.1 mg / dl
• GFR: 19%
• Weight loss of 3 kg from 53> 50 kg
• TD: 190/90 mmHg
2. Nutritional imbalance: less than body requirements associated with restricted
appetite as indicated by: Nausea, Vomiting and strict DS:
The client said that the stomach was bloated, the body was weak for 2 days, and the
weight loss was 3 kg in the last 3 months.
DO:
• The state of the client is moderate
• Meals that are consumed only 1P
• The client looks limp
• Urine within 24 hours 600cc
A.: BW: 50 kg TB: 150cm
BMI: 22 (overweight)
Ideal client weight: 45 kg - 55 kg.
B.: HB: 12.0 g / dl Ureum: 134 mg / dl Creatinine: 3.1 mg / dl
C.: ananemic conjunctiva, abdominal bloating, bowel sounds 18x / minute.
D.: client's diet 3 times / day. Low protein diet 40gr, low salt 40gr.