NURSING CARE FOR CLIENTS Ny.

E WITH CKD (CRONIC KIDNEY

DISEASE) IN PAVILLIUN CLASS 3B BUILDING

1. Identity

a. Patient identity

Name : Mr. S.

Age : 42 years

Religion : Islam

Gender : Male

Marital Status : Married

Education : Graduated from elementary school

Job : Craftsman Employee

Insurance :-

Ethnic Nation : Indonesia

Address : Ngunut Tulung-Agung

Entry Date : May 14, 2010

Assessment Date : May 17, 2010

Registration Number : 680394

Medical Diagnosis : CKD (Cronic Kidney Disease)

b. Person in Charge Identity

Name of Insurer : Ny. M

Relationship with Patients : Wife

Address : Ngunut-Tulung Agung

No. Telephone :-

Identity Card Number :-

Female : gender

Occupation : Private

2. Health History

a. Main complaint

Patients say shortness of breath, ampeg and stomach nausea ± since 3 weeks ago.

b. Current Disease History

The patient said that these 3-week breaths were suffocated especially for the
activity of swollen hands and feet and BAK was difficult, then the patient's family
was taken to the hospital. Baptist Kediri and diangnosa CKD

c. Past Medical History

Previous patients had never been sick like now. Px does not have endocrine
diseases such as DM

a. Family Health History

No family has the same disease as a patient

Genogram:

Keterangan :
: male : Marriage relationship

:Female : : Heredity Relations

: death : Only one house left

: Patient

b. Sociocultural History
Patients of the Islamic religion before being sick routinely perform prayers 5
times since being sick patients cannot perform prayers.

c. Review Healthy Patterns - Pain

Before illness patients can be invited to communicate well, full conscious

awareness (Composmentis)

d. Gordon's Health Function Pattern

1) Pattern of Perception and Health Management

The patient's family said previously px had never had this disease

2) Nutrition Pattern - Matabolic

Weight: 68 kg

Height: 160 cm

Eating habits at home: Rice, vegetables, side dishes, rare fruit. Drink 3-4
cups / day with water, coffee. No complaints at home

Hospital eating habits: diet with 3 grams of protein / kg / day

3) Elimination Pattern

At home CHAPTER: 1x / day routine (morning) when sick there is a change in

the pattern of CHAPTER, in the hospital CHAPTER: not CHAPTER, BAK:
installed catheter ± 500 cc / day

4) Activity and Exercise Pattern

Before being sick the patient can do ADL alone (independently), at home px
works as an entrepreneur

At the time of px bed rest totally, ADL is fully supported by family and nurses

5) Positive Patterns and Perceptions

The patient is unable to communicate, apathetic +

6) Perception Patterns - Self Concepts

Not reviewed

7) Sleep and Rest Patterns

At the time of illness the patient continues to sleep

8) Role Patterns - Relationships

Patients cannot relate well to all other family members or others, because px is
unconscious

9) Sexual Patterns - Reproduction

Px is married, the husband always accompanies his wife when ill

10) Stress Tolerance Pattern - Koping

When healthy, patients always talk about any problems faced with other families.

11) Value Patterns - Trust

Not revealed

3. Physical examination

a. General Conditions

KU is weak, semifowler position, shortness of breath and nasal oxygen 4 liters /

minute, ADL assisted by family, GCS 4-5-6

GCS Description:

4: able to open eyes spontaneously

5: able to answer all questions raised by nurses

6: able to make spontaneous movements

b. Vital Signs

Temperature: 36.50C Pulse: 84x / minute Breath: 26x / minute TD: 180/100
mmHg

c. Head

Black hair, no mass, no scars, dirty, no dandruff

d. Eye

No palpebrae edema, no icterus, isochoric pupils, pupillary reflexes to light ++ /

+, pink conjunctiva, white sclera

e. Nose

Normal nasal septum in the middle, no secret, no polyps, no bleeding, use nasal
canule 4 l / min, no nasal lobe breathing
f. Ear

Canalis is clean, has a little wax, no pus, no mass.

g. Mouth

Clean tongue, no halitosis, no lesions, no cyanosis, dry mucosa

h. Neck

There is no mass, no enlargement of the thyroid gland, no enlarged lymph nodes,

no stiff neck.

i. Chest and back

There are no chest deformities such as barrel chest, pigion chest etc., there are no
signs of intercostae retraction

Lung:

Regular breathing pattern 20x / minute, no additional breath sounds such as

crackles, wheezing etc., bronchovesicular no additional breath sounds, inspiration
is longer than expiration, sonor.

Heart:

Ictus cordis is on the left ICS 5 linea medio clavicularis 1cm wide, deaf, single S1
S2, no heart murmurs or additional heart sounds.

Back: There are no back deformities such as kyphosis, lordosis

j. Abdomen

acites, no surgical scars, no mass, bowel sounds 5x / minute, no tenderness in the

Mc Burney area, no enlarged liver, thympani.

k. Extremities

IV RL 500cc 20 drops / minute, no edema of the upper or lower extremities, no

clubbing of the finger, CRT <2s

MMT 5 5

5 5

Remarks 5: Strength intact, able to resist gravity and the resistance of the
examiner
l. Genetalia

Fitted Cathley Cath, clean, no erythema, no lesions.

m. Anus

No hemorrhoids, clean, no erythema

4. Supporting Data (Diagnostic Check)

Complete Blood Test Date 05-14-2010

EXAMINATIO RESULTS Normal Value interpretation

N

WBC 6.8 K/uL 4.1 – 10.9 K/uL Normal

LYM 0.9 24.4 %L 0.6 – 4.1 10.0 – 58.5%L Normal

MID 0.7 5.7%M 0.0 – 1.8 0.1 – 24.0%M Normal

GRAN 5.2 69.9%G 2.0 – 7.8 37.0 – 92.0%G Normal

RBC 1.42 M/uL 4.20 – 6.30 M/uL Menurun

HGB 5.6 g/dl 12.0 – 18.0 g/dl Menurun

HCT 11.3 % 37.0 – 51.0 % Normal

MCV 79.5 fL 80.0 – 97.0 fL Normal

MCH 25.4 pg 26.0 – 32.0 pg Normal

MCHC 31.9 g/dl 31.0 – 36.0 g / dl Normal

RDW 17.4 % 11.5 – 14.5 % Normal

PLT 113 K / ul 140 – 440 K/uL Menurun

Complete Blood Test Date 14-05-2010

Examination result Normal value Interpretation

BUN 176 mg/dl 10 – 23 mg/dl Normal

GDS 143 mg/dl 76 – 110 mg/dl Normal

Creat 21.1 mg/dl 0.5 – 1.1 mg/dl Normal

Na 136 mEq/L 136 – 145 mEq/L Normal

 K+ 3.74 mEq/L 3.6 – 5.0 mEq/L Normal

TC blood group B + can be transfused by PRC 500 cc on the date of 05-14-2010

BGA inspection dated 05-14-2010

Pemeriksaan Hasil Nilai Normal Interprestasi

pH 7.28 mmHg 7.350 – 7.450 mmHg Menurun

pCO2 18.2 mmHg 32.0 – 45.0 mmHg Menurun

pO2 135.2 mmHg 80-100 mmHg Meningkat

HCO3 8.4. mmol / L 22-26 mmol /L Menurun

BE - 8.4 mmol / L - 2 - +2 mmol / L Normal

SpO2 98.5 % 95 – 100 % Normal

5. Additional Data (Management)

1) Tonar 2 TID

2) Lasix 40 mg Iv q 6 hours

3) Clonidin 1 TID

4) Tensivask 10 mg qh

5) Dulcolactol syrup 2x30 cc

6) Vometa FT ½ hour AC

7) Neprisol 30 gr BID

8) Renal diet with protein 0.3 g / kg / day

DATA ANALYSIS

information material Etiology Collaborative Problems

/ Nursing
 DS: The patient said that Impaired regulatory Excess liquid volume
the breath is suffocated, mechanisms
ampeg
DO: Dx: CKD
1. 02 nasal 4 liters /
minute
2. Semifowler position
3. breath 26x / minute
4. Pale face
5. I am weak
6. Edema extremities
7. Stomach acites

2.3 List of Collaborative Problems / Nursing Diagnoses

Date /
Date / Time
No Time Collaborative Problems / Nursing Diagnosis
Resolved
found

1. 05-17- Excess fluid volume is associated with a decrease May 18-19,

2010 in plasma osmotic pressure which is characterized 2010
by the patient saying shortness of breath, ampeg,
10 am breathing 26x / minute, Dx: CKD, 02 nasal 4
liters / minute, semifowler position, pale face,
weak KU, weak edema, stomach acites

( NCP / NURSING CARE PLANS )

PLAN RATIONAL
1. Collaboration in the installation of 1. The installation of a fixed cateter
the catheter makes it easy to take measurements of
the intake output correctly
2. Knowing the status of fluid
2. Measure intake and output circulation adequately and identifying
fluid balance in the body
3. Increased blood pressure is
3. Observation of blood pressure every associated with excess fluid and is
4 hours useful for controlling anti-diuretic
administration
4. Displacement of fluids in tissues
4. Monitor the degree of edema resulting from sodium and water
retention
5. Instruct the patient to limit fluid 5. Minimizing fluid retention in the
intake extravascular area. Fluid restriction to
improve hyponatremia dilution
6. Collaboration in diuretic therapy 6. Diuretics can control odema / secrete
fluids from the body thereby reducing
tightness due to excess fluid

IMPLEMENTATION

DATE, DIAGNOSIS IMPLEMENTATION

HOUR
05-18-10 Excess fluid volume is associated with a 1. Collaboration in the installation
10 am- decrease in plasma osmotic pressure of the catheter
12 am which is characterized by the patient 2. Measuring intake and output
saying shortness of breath, ampeg, 3. Measuring vital signs
breathing 26x / minute, Dx: CKD, 02 4. Monitor the degree of edema
nasal 4 liters / minute, semifowler 5. Encourage patients to limit fluid
position, pale face, weak KU, weak intake
edema, stomach acites 6. Provide nasal oxygen as needed
7. Provide comfort measures such
as semifowler position, changing
 clothes that are wet with sweat
8. Collaboration in diuretic therapy
1). Silax 2 amp. IV

EVALUATION

DATE, DIAGNOSIS EVALUATION

HOUR
05-18-10 Excess fluid volume is associated with a S :
12 am
decrease in plasma osmotic pressure The patient says shortness of breath
which is characterized by the patient and ampeg
saying shortness of breath, ampeg,
breathing 26x / minute, Dx: CKD, 02 O :
nasal 4 liters / minute, semifowler 1. Dx: CKD
position, pale face, weak KU, weak 2. KU patient is still weak
edema, stomach acites 3. Lie in bed with semifowler
position
4. Breath 24x / minute
5. TD: 170/90 mmHg
6. Urine q 8 hours 250 c

A:
The goal has not been reached
1. The patient is still crowded
2. TD is above the normal limit
3. Urine production is below
normal

P:
Nursing action plan no. 1-6