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CASES FOR NURSING INTERVENTION

Disusun Oleh:

1. Elza Fauziah ( P3.73.20.1.20.019 )

2. Fadila Ajeng Arianti ( P3.73.20.1.20.020 )

3. Fanny Suri Rinaldo ( P3.73.20.1.20.021 )

Dosen Pengampu :

Sofia F. Rachmani, M.Pd

PROGRAM STUDI D III KEPERAWATAN JURUSAN KEPERAWATAN

POLITEKNIK KESEHATAN JAKARTA III
TAHUN 2022
CASES

Mrs. I, 46 years old. She comes to the hospital because of fluid electrolyte imbalance. Since 10
years past she was diagnosed chronic kidney disease. She complaints that she is feeling itchy in
all part of body, just excrete a little bit of urine. She said her dry body weight is 53,20 kg.

A. Pengkajian
I. Identitas Pasien
Name : Mrs. I
Age : 46 Years
Gender : Woman
Religion : Islam
Status : Marry
Education : SLTA
Profession : Housewife
Address : Jatibening, Bekasi
MR . Number : 637518
Date of entry : February 23, 2021
Study Date : February 24, 2021
Room : Rose
The name of the person in charge : Mr. M
Age : 50 Yerars
Family relationship : Husband
Profession : Privat Worker
Address : Jatibening, Bekasi

II. Medical history

a) Current Health History
The patient complains that he feels itchy all over his body, only urinating a little. The
patient said his dry weight was 53, 20 kg.
b) Past Medical History
 since ten years ago he was diagnosed with chronic failure.
c) Family Health History
- Husband of the patient suffers from hypertension.
- Wife suffers from chronic kidney failure for 10 years.

III. Physical Examination

a) Vital sign
- Blood pressure : 120/110 mmHg
- Pulse : 88x/menit
- Temperature : 36,6 °C
b) Head :
- Hair: No dandruff, good hair contribution, not easy to remove.
- Eyes: Conjunctiva anemic, sclera not icteric.
- Nose: Symmetrical left and right nostrils, no signs of inflammation.
- Mouth: Dry oral mucosa, adequate teeth, caries +
- Face: No edema
- Ears: left and right symmetrical auricles, good hearing function.
- Neck: no enlargement of the thyroid gland and lymph nodes.
- Thorax: Symmetrical
c) Abdomen: no abdomen
d) Heart: Normal heart sound, regular
e) Genitalia: Not checked
f) Extremities: No edema, good movement, IVFD infusion installed, EAS Premir 2 : 1,
D = 10%. Bottom a little edema, good movement.
g) Biological data: healthy nutrition = rice + side dishes + vegetables 3x a day
Sick = the portion of food provided is not finished, patient's diet = low salt, low
protein 40gr.
h) Drink: healthy = + 8 glasses/day + 1600 cc. Sick = 1000 cc
i) Elimination
- BAK: healthy = clear yellow color, distinctive odor 4-5 times / day
sick = clear yellow color, characteristic odor 2-3 times / day, 600 cc
 - CHAPTER: healthy = 1-2 times / day, sick = 1-2 times/day
- Bathing: healthy 2 x a day, brushing teeth 2 x a day.
Sick = the pain is only wiped once a day.
j) Supporting Investigation
A. Laboratory examination :
- HB 9.8 g/dl
- Blood urea: 206 mg/dl
- Creatinine: 15.2 mg/dl
- Sodium : 12.2 mg/dl
- Potassium: 4.3 mg/dl
- Leukocytes: 13,400/mm3
- Platelets: 243000/mm3
B. Radiology
- Ro. Thorax
- Kidney ultrasound
C. Drugs:
- Ceftriaxone 1 x 2 gr
- NTR 3 x 1
- Lasix 1 x 1
 B. ANALISIS DATA

DATA DIAGNOSA

DS: Disorders of Fluid and Electrolyte Balance

- The patient said he complained that he

felt itching all over his body.
- The patient said he weighed 53.20 kg
before getting sick
- The patient said he only urinated a little

DO:

- Poor Turgor
- Slightly edematous lower extremities
- Intake 1000cc output 600 cc
- HB : 9.8 g/dl
- Sodium : 122 mg/dl
- Creatinine: 15.2 mg/dl

C. DIAGNOSIS AND INTERVENTION

NO DIAGNOSSIS PORPOSE INTERVENTION

.
1. Impaired fluid and electrolyte Disorders of fluid and - measure TTV
balance related to decreased renal electrolyte balance can be - Check for filtering edema and
filtration treated with the following mucous membranes
criteria: - measure intake and output
- collaboration with other medical
- Edema reduced / teams
disappeared.
- Intake and output reduced

D. NURSING IMPLEMENTATION

NO DAY/DATE CLOCK ACTION RESPONSE PERSON

RESPONSIBLE
DX

DX Wednesday, 08.00 Measure the client's R: GROUP 6

1 February 23, vital signs
- TD: 170/100
2022
- S: 36,4 C
- N: 92X

09.05 Check skin turgor and R: GROUP 6

mucous membranes
- The patient
says there is
pee but a
little
10.00 Measuring R: GROUP 6
intake/output - intake 100cc
- Output
600cc
11.00 Collaborating with a R : GROUP 6
team of doctors in - The patient
 treatment said his
drinking
increased

E. DEVELOPMENT NOTES

IMPLEMENTATION Evaluation

- Measure the client's vital signs TD S : - The client said there was BAK but a little
170/100, S. 36.4 : N. 92 x/i
O: - Good skin turgor
- Check skin turgor and mucous
membranes - Extremities that are edematous
- Measuring intake/output intake 1000cc
A : -The goal has not been achieved
Output 600 cc
- Collaborating with the team of doctors in P : - Intervention continues
the treatment of clients