Analisa Data

Data Problem Etiology

DS : The patient said he was thirsty Fluid volume deficits Associated with hypovolemic shock due to the
dialysis process
DO : bleeding, dry mucous membranes, weight decreased,
decreased urine output, hypotension, dark urine color,
imbalance of intake and output, an increase in serum
sodium, BP <120/80 mmHg, pulse >60 - 100x / min, S>
36,50C - 370C , RR 16 - 20x / min.

Activity Intolerance Associated with decreased range of motion

DS : Patients report feeling dizzy, difficult to move and
secondary to the ability of the dialysis process.
muscle cramps.
DO : Patients seem difficult to move, limited range of
motion, BP <120/80 mmHg, pulse> 60 - 100x / min, S>
36,50C - 370C, RR 16 - 20x / min,Hb <

Hyperthermia Associated with an increase in body

DS : Patients say the body feels the heat
temperature secondary to inflammation.
DO : Hot body perfusion, mucosal dry lips, face looks red,
the body appears limp, BP <120/80 mmHg, pulse> 60 -
100x / min, S> 36,50C - 370C, RR 16 - 20x / min.
DS : - High Risk of infection related to the stabbing of AV shunt.
DO : there is mounting AV shunt of the blood vessels in
the hands of patients.
 Diagnosa Keperawatan

1. Fluid volume deficits associated with hypovolemic shock due dyalisis process is characterized by the patient said she felt thirsty,
dehydrated, dry mucous membranes, dark urine color, weight decreased, decreased urine output, hypotension, imbalance intake and
output, an increase in serum sodium, BP <120 / 80 mmHg, pulse> 60 - 100x / min, S> 36,50C - 370C, RR 16 - 20x / min.

2. Activity intolerance related to decreased range of motion secondary to the ability dyalisis process characterized by the patient said she
felt dizzy, difficult to move and muscle cramps, patients seem difficult to move, limited range of motion, BP <120/80 mmHg, pulse> 60 -
100x / min, S > 36,50C - 370C, RR 16 - 20x / min.

3. Hyperthermia is associated with increased body temperature secondary to inflammation characterized by, patients say the body feels hot,
hot body perfusion, mucosal dry lips, face looks red, the body appears limp, breathing kusmaul, BP <120/80 mmHg, pulse> 60 - 100x /
min, S> 36,50C - 370C, RR 16 - 20x / min.

4. High Risk of infection related to the stabbing of AV shunt associated with the insertion of the AV shunt characterized by the installation
of AV shunt in the hands of patients.

5.

Intervensi Keperawatan
NO Nursing Diagnosis Purpose / Criteria Results Intervention Rationale

1. Fluid volume deficits associated with lost Fluid volume deficits can be
of water and electrolitr due dyalisis resolved after the act of nursing
process characterized by the patient said for 3 x 24 hours with expected
she felt thirsty, dry mucous membranes, outcomes:
dark urine color, weight decreased, 1. Patient Cooperative
decreased urine output,imbalance intake 2. intake and output balance
and output,decreased potasium, BP 3. Body Weight increased
<120/80 mmHg, pulse> 60 - 100x / min, 4. Color clear urine
S> 36,50C - 370C, RR 16 - 20x / min. 5. Normal Blood Plessure
6. Normal serum podium (135
mEq / liter - 145 mEq / liter)
7. Vital signs normal
1. Explain to patients 1. By allowing the
nursing actions to be patient to understand the
performed and its situation explanation and
purpose. cooperative to nursing
actions
2. Provide patient drink 2. By providing the
according to the patient drink enough
indication. fluids can meet the needs
of the body so as to reduce
dehydration.
3. By providing a
3. Collaboration with
liquid containing sodium
physicians in providing
can regulate water and
the liquid containing
electrolyte balance in the
potasium
body

4. By monitoring
4. Monitor intake and
 output every 24 hours intake and output balance
can determine the volume
of fluid in the patient's
body.

5. To determine the
5. Observation of the
level of dehydration status.
color of urine.
6. Observation the
6. With the weigh can
patient's weight.
determine the level of
dehydration status.
7. Check serum potasium
7. By examination of
serum sodium can find
water and electrolyte
balance in the body.

8. Observations of vital
8.
signs
 Normal blood
pressure is an
indicator of the
stability of the
 hemodynamics of
the body.
 Nadi normal
hemodynamic
stability is an
indicator of the
body.
 Temperature
stability is an
indicator of normal
body
thermoregulation.
 RR is normally an
indicator of
respiratory stability.

2. Activity intolerance related to weekness Activity intolerance can be 1. Explain to the patient's 1. The explanation
csuse by anemia characterized by the resolved after the act of nursing nursing actions to be allows the patient to
patient said she felt dizzy, difficult to move for 3 x 24 hours with the performed and its understand your
and muscle cramps, patients seem difficult outcome criteria: purpose. situation and
to move, limited range of motion, BP 1. Patient Cooperative cooperatively to
<120/80 mmHg, pulse> 60 - 100x / min, S 2. Dizziness reduced
> 36,50C - 370C, RR 16 - 20x / min,Hb<, 3. Reduced muscle cramps 2. Provide a comfortable
kalium < 4. The patient was able to position for the patient.
move
5. Vital signs Normal
6. Hb normal 3. Collaboration with
7. Kalium normal physicians in the
follow-up treatment.
4. Collaboration with
physicians to give
sangobion drug.
5. Collaboration with
physicians to give
KCL.
nursing actions.
2. By providing a
comfortable position
can increase comfort
to the patient.
3. With the
collaboration can
provide appropriate
interventions to
overcome the
problems faced
fatherly patients.
4. Sangobion drug can
make Hb increased
5. KCL can make
kalium increased
6. By observing the
patient's ability to
move can determine
 changes in the
6. Observe patient's
patient's ability to
ability to move.
move.
7. The patient did not
complain of
dizziness and muscle
cramps is an
indicator of the
7. Ask the patient about
activity disturbance
perceived grievances.
resolved.

8.
 Normal blood
8. Observation Vital signs
pressure is an
indicator of the
stability of the
hemodynamics of
the body.
 Normal pulse is an
indicator of the
stability of the
hemodynamics of

3. Hyperthermia is associated with increased Hyperthermia can be resolved
body temperature secondary to after the act of nursing for 3 x
inflammation characterized by, patients 24 hours with the outcome
say the body feels hot, hot body perfusion, criteria:
mucosal dry lips, face looks red, the body 1. Patients Koopertif
appears limp, breathing kusmaul, BP 2. Patients didn’t complain
<120/80 mmHg, pulse> 60 - 100x / of body feels hot
minutes, S> 36,50C - 370C, RR 16 - 20x / 3. warm body perfusion
min. 4. mucosa moist lips
5. Limp reduced
6. The skin doesn’t look
the body.
 Normal temperature
is an indicator of the
stability of the body
thermoregulation.
 RR is an indicator of
normal respiratory
stability.
1. Explain to the patient's 1. The explanation
nursing actions to be allows the patient to
performed and its understand the
purpose. situation is and
cooperative to
nursing actions.
2. Instruct the patient to 2. By wearing thin
wear thin clothing can give off
heat in evaporation.
3. Modification of the 3. By modifying the
environment according environment can
 red to the condition of the remove heat
7. Vital Signs normal patient. radiation.

4. Give cold compress on

4. By providing a cold
patients.
compress can
stimulate
vasodilation of blood
vessels so that the
heat can descreased.

5. Palpation of the
5. Perfusion of the
patient's body
patient's body is still
perfusion
hot is an indicator of
hyperthermia that
have not been
resolved.

6. Observations mucosal 6. mucosa was dry lips

lip patients. is an indicator of
hyperthermia that
have not been
resolved.
 7. The patient's skin
7. Observasi patient's skin
still looks red is an
indicator of
hyperthermia that
have not been
resolved.

8. Observation patients
8. Patients still looks
Conditions
weak is an indicator
of hyperthermia that
have not been
resolved.

9. Ask the patient about 9. Patients do not

perceived grievances. complain of hot
body hyperthermia is
an indicator that is
resolved.

10. Observations of vital

10.
signs
  Normal blood pressure is
an indicator of the
stability of the
hemodynamics of the
body.
 Normal pulse is an
indicator of the stability
of the hemodynamics of
the body.
 Normal temperature is
an indicator of the
stability of the body
thermoregulation.
 RR is an indicator of
normal respiratory
stability.

4. High Risk of infection related to the High Risk of infection the risk 1. Explain to the patient's 1. The explanation
stabbing of AV shunt associated with the of infection does not occur nursing actions to be allows the patient to
insertion of the AV shunt characterized by during nursing actions performed and its understand your
the installation of AV shunt in the hands of performed purpose. situation and
patients. outcome criteria: cooperatively to
1. Patient cooperative nursing actions.
2. no sign of infection 2. doing maintenance 2. can maintain the
around the mounting sterility of the area
area av shunt around the mounting
av shunt and prevent
the entry of bacteria

3. maintain sterility of the 3. can prevent the entry

equipment used of bacteria through
used medical
equipment
4. maintain sterility of the 4. can prevent the entry
room around the of bacteria
patient

5. observation for signs of 5. to know the signs of

infection in the area infection
around the mounting
AV shunt