1. The patient is Mr. Wibowo, a 50-year-old male who was admitted to the hospital on September 25, 2019 complaining of shortness of breath, nausea, and leg swelling.
2. Upon assessment, the patient had tachycardia, tachypnea, ronchi in the lungs, edema in the left leg, and lab results indicating chronic kidney disease and anemia.
3. The nursing diagnoses identified include ineffective airway clearance related to retained respiratory secretions, nutritional imbalance related to chronic kidney disease, and edema related to excess fluid volume from chronic kidney disease. Plans of care were developed to address each diagnosis.
1. The patient is Mr. Wibowo, a 50-year-old male who was admitted to the hospital on September 25, 2019 complaining of shortness of breath, nausea, and leg swelling.
2. Upon assessment, the patient had tachycardia, tachypnea, ronchi in the lungs, edema in the left leg, and lab results indicating chronic kidney disease and anemia.
3. The nursing diagnoses identified include ineffective airway clearance related to retained respiratory secretions, nutritional imbalance related to chronic kidney disease, and edema related to excess fluid volume from chronic kidney disease. Plans of care were developed to address each diagnosis.
1. The patient is Mr. Wibowo, a 50-year-old male who was admitted to the hospital on September 25, 2019 complaining of shortness of breath, nausea, and leg swelling.
2. Upon assessment, the patient had tachycardia, tachypnea, ronchi in the lungs, edema in the left leg, and lab results indicating chronic kidney disease and anemia.
3. The nursing diagnoses identified include ineffective airway clearance related to retained respiratory secretions, nutritional imbalance related to chronic kidney disease, and edema related to excess fluid volume from chronic kidney disease. Plans of care were developed to address each diagnosis.
1. The patient is Mr. Wibowo, a 50-year-old male who was admitted to the hospital on September 25, 2019 complaining of shortness of breath, nausea, and leg swelling.
2. Upon assessment, the patient had tachycardia, tachypnea, ronchi in the lungs, edema in the left leg, and lab results indicating chronic kidney disease and anemia.
3. The nursing diagnoses identified include ineffective airway clearance related to retained respiratory secretions, nutritional imbalance related to chronic kidney disease, and edema related to excess fluid volume from chronic kidney disease. Plans of care were developed to address each diagnosis.
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Name : Fitri Mulyaningsih Nim : P17210184110
Study program : D3 Nursing / 2B Subject : English
BASIC NURSING ASSESSMENT FORMAT
A. ASSESMENT
I. BIODATA a. Client identity Name : Mr. Wibowo Age : 50 years Gender : Male religion : Islam Address : Street. Venolia No. 85 Occupation : Privat No. medrek : 567811 Room : Tulip Dx. medical : Chronic Kidney Disease Date of entry : September 25, 2019 at 13.00 Date of assesment : September 25, 2019 at 15.00 b. The identity of the person in charge Name : Mrs. Parmi Age : 45 years Gender : Male Address : Street. Venolia No. 85 Religion : Islam Relationship with client : Wife
c. Main Complaint Shortness of breath and nausea
d. Current Medical History
Patient complained Shortness of breath 1 month before entering the hospital. The complaint felt worse when do activity and improved if a break. The patient also experienced limp, nausea and vomiting of food mixed fluid,chest pain, limp body and a cough with sputum are white yellow for 3 days. Patients also complain of no appetite. The patient also complained that the left leg of the leg was swollen and felt thick, and also the left foot was swollen.
e. Medical History first
The patient said have been hospitalized with illnesses of constriction of the heart and hypertension 3 month ago.
f. Family health history
The patient said in his family did not have a history of disease like a patient and other infectious diseases
g. Psychological aspect The patient expressed anxiety about the disease. But patients are always obedient in following all the suggestions from the health team. The patient said that he had resigned himself to the situation he was in.
h. Social aspect 1. Communication relations The patient is very listening and responds well when invited to communicate. 2. Cultural factors The patient is a private employees 3. Dependency level Patients are still able to fulfill their basic needs independently. Patients do not need the help of others to meet their basic needs.
i. Spiritual aspect Patients and families adhere to the religion of Islam, families always pray for the good of the patient and healing the patient. Patients say that they are always obliged to perform the 5 daily prayers on time.
II. PHYSICAL EXAMINATION
General Conditions : 1. Impression of pain : Medium Awareness : Composmentis 2. BMI : 17,7 Height : 150 cm Weight : 40 Kg 3. Vital sign : - Blood pressure : 145/100 - Temperature : 36,8 °C - Pulse : 122 x/minute - Respiratory rate : 26 x/minute 4. GCS : 456 5. Head and neck examination : Head shape : mesochepal, White hair, straight, evenly distributed, anemic conjunctiva (+), jaundice sclera (-), dry mucosa, pale face 6. Press pain: positive in the epigastric region 7. Auscultation Lungs : - breathing rhythm : Irregular - Additional sounds: ronchi ++ / + rough wet, wheezing is absent 8. Abdomen Examination - Inspection Form : flat Movement of breath time : Normal - Palpation Abdominal wall: soft, supple P Ress pain : positive in the epigastric region Basic needs a. Fluid : Fluid Requirement : 2.200 intake: 1500 + 700 = 2200 output: 600 iwl: 750 fluid balance: 2200 – 1350 = +850 b. Food: 3x a day c. Sleep pattern : 6-7 hours f. Elimination: 2x/ days Supporting Investigation 1. Blood Lab Examination at 25 September 2019 - Blood complete Hemoglobin : 9,2 (N : 14-18g/dL) Hematorit : L. 27 (N : 35-50 gr/dl ) Leukosit : 14.000 ( N : 4000-10000 /μL) Eritrosit : L 3.2 ( N : 1,2 million – 1.5 million /μL ) Trombosit : 200.000 ( N : 150.000 – 350.000 /μL ) - The chemistry of blood Ureum : H 155,3 ( N : 3.500 – 10.000 / μL ) Creatinine : H 9.98 ( N : 0.7 – 1.5 mg/dl ) III. DATA ANALYSIS
NO DATA PROBLEM ETIOLOGY
1 DS : Patients says of Shortness of Ineffectiveness of the Airway obstruction breath airway clearance
DO : 1. dyspneu Mucous hypersecretion 2. Respiratory rate : 26 x/minute (tachypnea) 3. Pulse : 122 x/minute (tachycardia) secretions retained in the 4. Sputum ( + ) respiratory tract 5. Ronchi ( + ) 6. Cough is not effective 7. Breathing rythm : Irreguler ronchi
Ineffectiveness of the airway clearance
2 DS : Patient says nausea, vomiting of nutritional imbalance: Chronic Kidney Disease food mixed fluid, and no appetite less than the body's needs
DO : 1. nutritional status : BUN, Creatinin BMI : 17.7 Weight : 50 kg Height : 150 cm 2. vomited once after eating and Waste production in the drinking bloodstream 3. dry mucosa 4. anemic conjunctiva 5. hemoglobin : 9.2 gram/dl (N : 14-18g/dL) In the GI channel 6. hematokrit : 27 gram/dl (N : 35-50 gr/dl )
Nauseous, vomit Nutritional imbalance: less than the body's needs
3 DS : The patient complained that the Excess fluid volume Chronic Kidney Disease left leg of the leg was swollen and felt thick, and also the left foot was swollen. Decreased blood protein levels DO : 1. there is edema in the left leg 2. Ureum : H 155,3 ( N : 3.500 – 10.000 / μL ) Fluid out to the 3. Creatinine : H 9.98 extravascular ( N : 0.7 – 1.5 mg/dl ) 4. fluid balance results : +850
Hydrostatic pressure increases
Edema
Excess fluid volume
B. DIAGNOSA KEPERAWATAN
NAMA & TANDA
NO TANGGAL DIAGNOSA KEPERAWATAN TANGAN PERAWAT C. RENCANA TINDAKAN KEPERAWATAN
NAMA & TANDA
DIAGNOSA TUJUAN DAN NO INTERVENSI RASIONAL TANGAN KEPERAWATAN KRITERIA HASIL PERAWAT NAMA & TANDA DIAGNOSA TUJUAN DAN NO INTERVENSI RASIONAL TANGAN KEPERAWATAN KRITERIA HASIL PERAWAT D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN
NAMA & TANDA
NO TANGGAL JAM TINDAKAN KEPERAWATAN TANGAN PERAWAT E. EVALUASI
