NURSING CARE OF THE PATIENT WR

WITH ACKD (Acquired Cystic Kidney Disease)

IN GANESHA HOSPITAL
DATE 1 - 12 JUNE 2015
I. ASSESSMENT
A. Identity Of The Patients
Patients came to the Ganesha Hospital on May 18, 2015. For the assessment
started on Monday , June 1 2015 at 9 oclock and the ward of the inpatient for patient
is at third floor in Cempaka Ward number 311 E. Information obtained through a
method of an interview with the patient's family, physical examination, and
observation . `
1. Identity Of The Patients
Name
: WR
Caretaker
Gender
: Male
NW
Age
: 77 years old
Marital Status
: Married
Male
Religion
: Hindu
43 years old
Nation
: Indonesia
Last educational
: Elementary School (SD)
Married
Occupation
: Not Working
Hindu
Address
: Br. Gelumpang Sukawati
Medical Diagnostics: ACKD + PNA + Batu Ginjal + HHD Indonesia
Cost Sources
: JKBM
Senior High School
The Relationts with the patients :
Number of Medical Record
: 064696
Private Employees
B. The Reasons is in Hospital
1. The Main Complaint
When the Hospitalized : The complaint of the patient is about abdominal pain.
When to do the assessment : The complaint of the patient is about shortness.
2. Disease History
The patient came to the Ganesha Hospital on the may 18 2015
with
his patient
family.The
Son
of the
patient came conscious with the complaints abdominal pain , after examination by
a doctor ,patient are diagnose with PNA, a Kidney Stone and Hipertentiont Heart
Disease (HHD). In Emergency room patients get therapy:
- IVFD Nacl 3% 20 tpm makro
- Farmadol fles 1000mg
- Cefosubactam 1g
- Metronidazole 1000mg
- Captropil 25mg
- Amlodipin
The ward of the inpatient for patient is at third floor in Cempaka Ward number
311 E: and patients get therapy ~
- IVFD Futrolit 20 tpm makro
- Farmadol fles 1000mg k/p

- Captropil tablet 2 x 50mg

- Metylpredysolon injeksi 3 x 20 mg
- Furosemide injeksi 2 x 20 mg
- Cefo sulbactam injeksi 2 x 1 g
- Nucral syr 3 x 1 CI
- Omeprazole injeksi 2 x 40 mg
- Asam traneksamat injeksi 3 x 500 mg
C. The History of Previous Health
The patient said that he has high blood pressure since 10 years ago .
D. The History of Family Healt
The son of patients said in his family said there is no one to have the same disease
suffered by patients
E. The Necessity of Bio-Psiko-Sosial-Spiritual
1. Breathing
When to do the assessment the patient complain about feel shortness.
2. Eat and Drink
When to do the assessment patients get a diet sonde 2000 calories 40 gr protein
.The family said when the patient get sonde patients can only spend sonde that
given from the hospital. The family also said patients refused to eat and given
sonde .
3. Elimination ( BAB, BAK )
When to do the assessment patient had been chapter 1x with a mushy consistency
colored black with a little fishy smell. As well as tubs patients 1100 cc , with a
yellow color , a distinctive odor urine .
4. Activity
When to do the assessment the activity of the patient can help by his son, the
patients only capable of sloping left and right oblique , patients more be active in
bed because they felt weak .
5. Recreation
When to do the assessment the patient said that he cant go anywhere and he just
stay in his room, and sometimes to talk with families and other people that who
come to see .
6. Rest and sleep
When do the assessment the patients said he doesnt got a disturbed in his sleep ,
even in the hospital patient often sleep , For a night patien slept statr from 21.0006.00 oclock and during the daytime patient slept start from 13.00-15.00 oclock .
7. Personal Hygiene
When do the assessment The patients only wipe course twice a day with the help
patients son to cleanliness self patient awake .Patients look clean and after in a
wipe course by the family
8. Body Temperature

When do the assessment the patient said he doesnt feel cold or warm in his body,
the temperature is 36,1 0C.
9. Comfortable Felt
When do the assessment the patient said patient doesnt complaint about his pain.
10. Safe Felt
When do the assessment patients feel axious about his condition of disease and
that had happened to him now.
11. Study
When do the assessment the families of patients want to know and want to learn
about the ways to cure diseases suffered by patients. Family always following
therapy of the patient that advocated by doctors .
12. Occupation
When do the assessment the families of patient said about patient doesnt work
after he got hospitalized.
13. Socialitatoni and Communication
When do the assessment the families of the patien said , patients want to interact
with anyone good nurses and families inclined to the hospital. And he doesnt has
a problem in communication.
14. Spiritual
When do the assessment patients said during in hospital patients do prayer on the
bed.
F. Physical Examination
1. General State Of the Patient
The general impression : Weak
Awareness
: Compos Mentis GCS (E=4, M=5, V=6)
Posture
: Erect
Weight
: 62 kg
Height
:165 cm
Turgor the skin
: not elastis
Skin Colour
: Sapodilla ripe
2. Cardinal Symptom
Blood Pressure
: 170/90 mmHg
Temperature
: 36,1 0C
Pulse
: 90 x/minute
Respirations
: 12 x/minute
3. Physical Condition
1) Head
Inspection

:
: Cleanliness good , the spread of hair evenly , there is no
lesions , looked listless the face , of hair color partially

Palpasi
2) Eyes

white.
: There is no pain pressure.
:

Inspection

:Symmetrical forms, white of the sclera, pale the

Palpasi

conjunctiva, pupil isokor, no lesions.

: There is no pain pressure.

3) Nose
Inspection

:
: Attached NGT in the nostrils right, symmetrical forms,
there is no lesions, cleanliness enough, there are the
breath of the nostrils, patients with attached o2

Palpasi

4) Ears
Inspection
Palpasi

kanulanasal 3 l / minutes.
: There is no pain pressure

:
: Symmetrical forms, cleanliness enough, there is no
lesions, there was no swelling. Of hearing fine.
: There is no pain pressure, good hearing.

5) Mouth and tooth :

Inspection
: Cleanliness enough , looked bleeding in the area of the
mouth and gums , the colour of lips is pale , mucous lips
6) Neck
Inspection
Palpasi

dry .
:
: There is no lesions
: There is no dam the jugular vein , not there is enlargement
of the thyroid gland , there is no pain pressure.

7) Thorax
Inspection

:
: Symmetrical forms, there is no lesions, there are retraction

Palpasi
Percussion

help respiratory muscles.

: There is no pain pressure
: Resonant voice sounded the part of the thorax right , and

Auskultasi
8) Abdomen
Inspection

sound dalnes in ICS 3 , 4.5 , 6 left

: A vesicular breathing
:
: Symmetrical form, there is no distention , there is no

Auskultasi
Percussion
Palpasi
9)

The extremities

lesions, umbilical is clean.

: Noisy intestines x / 20 minutes
: Audible of tympanic
: There is no pain pressure

Top

Symmetrical forms , there is no cyanosis , on the right

hand attachead IVFD fluktrolit infusion of 20 tpm. CRT

Bottom

< 2 seconds.
: Symetrical forms, there is no cyanosis, there is no
lesions and there is no pain pressure.

G. Investigations
The results of the examination of the pathology lab clinic on May 31, 2015
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Indicator
WBC
LYM%
MID%
GRA%
LYM
MID
GRAN
RBC
HGB
HCT
MCV
MCH
MCHC
RDW%
RDWa
PLT
MPV
PDW
PCT
LPCR

Result
14.7
11.1
7.0
81.9
1.6
1.1
12.0
2.73
8.2
23.1
84.6
30.2
35.7
15.4
84.4
106
9.0
13.8
0.09
24.0

Unit
109/l
%
%
%
109/l
109/l
109/l
1012/l
g/dl
%
Fl
Pg
g/dl
%

A reference value
4.8-10.8
20.0-40.0
3.0-9.0
50.0-70.0
0.8-4.8
0.1-7.0
2.0-7.0
4.7-6.1
15.4-18.0
42.0-52.0
79.0-99.0
27.0-31.0
33.0-37.0
11.5-14.5
30.0-47.0
150.0-450.0
7.2-11.1
10.0-17.0
0.2-0.4
0.1-99.9

fl
109/l
fl
fl
%
%
The results of laboratory examination on June 2, 2015
No
1
2
3

Indikator
WBC
LYM%
MID%

Result
15.9
12.1
5.3

Unit
109/l
%

A reference value
4.8-10.8
20.0-40.0
3.0-9.0

4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

GRA%
LYM
MID
GRAN
RBC
HGB
HCT
MCV
MCH
MCHC
RDW%
RDWa
PLT
MPV
PDW
PCT
LPCR

82.6
1.9
0.9
13.1
3.09
9.1
26.4
85.4
29.5
34.5
15.7
88.7
123
7.9
12.2
0.09
15.5

50.0-70.0
0.8-4.8
0.1-7.0
2.0-7.0
4.7-6.1
15.4-18.0
42.0-52.0
79.0-99.0
27.0-31.0
33.0-37.0
11.5-14.5
30.0-47.0
150.0-450.0
7.2-11.1
10.0-17.0
0.2-0.4
0.1-99.9

%
109/l
109/l
109/l
1012/l
g/dl
%
Fl
Pg
g/dl
%
fl
109/l
fl
fl
%
%

The results of laboratory examination on May 31, 2015

Parameter
Hasil
BUN
192.6
Creatinin 6.1

Rujukan
6 - 20
0.8 1.3

Satuan
mg/dl
mg/dl

Specimen keterangan
H
H

II. NURSING DIAGNOSIS

A. Data Analysis
Focus Data

No
1

DS :

Etiology

Nursing

Chronic Renal Failure

Problem
Ineffective

The patien said he is felt

shortness

DO :

Breathing
GFR decreased

Pattern

Metabolic Acidosis

Respiratory : 12 x/minute
There is a retraction

breathing muscle
There is the breath of the

nostrils
Attached with

Hyperventilation
Ineffective Breathing
Pattern

kanulanasal 3 l/minute
2

DS :
-

Level of Hb, Ht,

Patient said that he felt

Erytrocytes declining

Activity
Intolerance

weak
DO :
-

Hypoxia
The face of patient looked
languid and pale.

HGB : 8.2

RBC : 2.73

Pulse

Respiratory: 12 x/minute

: 90 x/minute

An imbalance of supply
with consumption O2
Weariness
Activity Intolerance

DS :
-

Chronic renal failure

Patient said that he felt
weak

DO :
-

The colour of lips and

conjungtiva is pale
HB : 8,2

Colaboratif
Problem of

Disorders of the acid

balance

Gastric Acid Increasing

Irritation in the gastric

Hematemesei Melena

Anemia

Anemia

Coaboratif problem of
anemia

DS :
-

Retention Na
Patient said that he felt
weak

DO :
-

Colaboratif
problem of

JG stimulated so that
renin out

Hipertention

Blood Preassure :
170/90 mmHg
Renin
+angiotensisnogen=
angiotensinogen 1

Angiotensinogen 1+PCE
= Angiotensinogen II

Entered tunika media

Suffered kontriksi fase

Colaboratif problem of
Hipertention
5

DS :
-

The family of the patient

Disorder of the acid

balance

said that when the

patient give sonde only
able to spend sonde

The family of the patient

Altered: Less
than Body

Gastric Acid production

increasing

that given from the

hospital .

Nutrition,

Irritation in the gastric

Requirements

also said patients

sometimes refuse to

Gastritis

given sonde that get

from the hospital.
Nausea and Vomiting

DO :
-

Looks bleedings in the

mouth and gums.

The colour of his lips is

pale

Nutrition, Altered: Less

than Body
Requirements

Lips of the mucous is

dry

Attached NGT

HB : 8,2

B. Diagnosa Keperawatan
1. Ineffective Breathing Pattern related to hiperventilation as evidenced by the
patient felt shortness, respiratory 12 x/ minute, there is a retraction breathing
muscle, there is the breath of the nostrils, attached with kanulanasal 3 l/minute
2. Activity Intolerance related to an imbalance of supply with consumption O2 as
evidenced by patient said that he felt weak, the face of patient looked languid and
pale, HGB : 8.2, RBC : 2.73, pulse: 90 x/minute, respiratory: 12 x/minute
3. Colaboratif Problem of Anemia related to hematemesis melena as evidenced by
patient said that he felt weak, the colour of lips and conjungtiva is pale, HB : 8,2.
4. Colaboratif problem of Hipertention related to angiotensin hormone increases as
evidenced by patient said that he felt weak, blood preassure : 170/90 mmHg
5. Nutrition, Altered: Less than Body Requirements related to irritation in the gastric
as evidenced by the family of the patient said that when the patient give sonde
only able to spend sonde that given from the hospital, the family of the patient
also said patients sometimes refuse to given sonde that get from the hospital,
looks bleedings in the mouth and gums. the colour of his lips is pale, lips of the
mucous is dry, attached NGT, HB : 8,2

III. INTERVENTIONS
A. The diagnosis of priority

1. Ineffective Breathing Pattern related to hiperventilation as evidenced by the

patient felt shortness, respiratory 12 x/ minute, there is a retraction breathing
muscle, there is the breath of the nostrils, attached with kanulanasal 3 l/minute
2. Colaboratif Problem of Anemia related to hematemesis melena as evidenced by
patient said that he felt weak, the colour of lips and conjungtiva is pale, HB : 8,2.
3. Colaboratif problem of Hipertention related to angiotensin hormone increases as
evidenced by patient said that he felt weak, blood preassure : 170/90 mmHg
4. Nutrition, Altered: Less than Body Requirements related to irritation in the gastric
as evidenced by the family of the patient said that when the patient give sonde
only able to spend sonde that given from the hospital, the family of the patient
also said patients sometimes refuse to given sonde that get from the hospital,
looks bleedings in the mouth and gums. the colour of his lips is pale, lips of the
mucous is dry, attached NGT, HB : 8,2
5. Activity Intolerance related to an imbalance of supply with consumption O2 as
evidenced by patient said that he felt weak, the face of patient looked languid and
pale, HGB : 8.2, RBC : 2.73, pulse: 90 x/minute, respiratory: 12 x/minute

3. Nursing Interventions
No

Date

Dx

Patient Outcomes

1.

Monday, June

After 3 x 24 hours of nursing

1st 2015
09.00 am

Interventions
1.

Measure the vital signs every 8 hours

care , expected patients

breathing pattern back to

2. Give semi-Fowler position

normal / stable with

3. Instruct the patient to deep breathing or

outcomes:
- The rhythm of breath,
respiratory frequency
in the normal range,
-

no additional sound.
Vital signs in normal
range

breath lips slowly according to patients

ability
4. Collaboration to give oxygen therapy

Rationale
1. To facilitate the provision of
appropriate interventions
2. To maximize ventilation
3. To facilitate breathing so more O2
that entered
4. Supply O2 is enough to reduce the
work of breathing

Monday, June

1st 2015
09.00 am

After 3 x 24 hours of nursing 1. Monitor for signs of anemia such as pallor,

1. To facilitate the provision of

care , expected expected to

dyspnea when breathing

2. Monitor of laboratory hematology like Hb,

appropriate interventions
2. To determine the effectiveness of

RBC
3. Instruct how to prevent bleeding, such as

treatment programs
3. Bleeding in any place in the body can

using a soft brush to brush his teeth.

4. Give HE to the family to give patients food

aggravate anemia
4. Iron is one of the ingredients in the

that containing of iron

5. Collaboration in giving blood transfusions as

formation of blood cells.

5. To increase the levels of Hb, RBC,

minimize the occurrence of

sustained anemia with
outcomes :
- Patients do not look
-

pallor
Results of laboratory
hematology (Hb,

indicated

HCT, PLT.

RBC) within normal

range

Monday, June
1st 2015
09.00 am

After 3 x 24 hours of nursing

1. Observation of patient's blood pressure

care , expected patient's blood

Vital signs in normal

Blood pressure measurements

provide objective data for

pressure is controlled with

outcomes:

1.

2. provide advice to adhere to dietary and

fluid restrictions.

monitoring patients condition..

2. Compliance with dietary
restriction and dialysis fluid
prevents the buildup of excess

range

fluid and sodium.

3. indication for inadequate control
3. Instruct the patient to report signs of fluid
overload, headache, edema or seizures.

of hypertension and the need for

change the therapy
4. antihypertensive medications has
important role in the treatment of

4. Give antihypertensive medications

4

Monday, June
1st 2015
09.00 am

After 3 x 24 hours of nursing

according to doctor instructions.

1. Assess etiologic factors from reduced

care , expected the problem

nutritional intake. (anorexia, nausea,

of inbalanced Nutrition, Less

vomiting, an unpleasant diet, depression,

Than Body Requirements is

lack of understanding of diet restriction,

resolved with outcomes :

-

An increase in the arm

circumference

There were no
significant weight loss

Shows the tasting and

swallowing function

stomatitis).
2. Provide appropriate food diet prescribed by a
physician nutrition and installation
3. Increase protein intake containing high
biological value such as eggs, dairy products,
meat.
4. Encourage low-protein, high-calorie and low
sodium snack between meals.
5. Change the medication schedule so the
medication is not given immediately before a
meal.
6. Explain the rationale and relation dietary
restrictions with kidney disease and an

hypertension due to CKD.

1. Providing information on other
factors can be changed or
removed to improve dietary input.
2. Encouraging increased dietary
inputs.
3. Complete proteins are used to
achieve nitrogen balance
necessary for growth and healing.
4. Reduce food and protein restricted
and provide calories for energy.
5. Ingestion of medication before
meals causes anorexia and satiety.
6. Improve the patient's
understanding of the relation
between diet, urea and creatinine
with dietary restrictions.
7. Unpleasant factors in meal times

increase in urea and creatinine.

7. Create a pleasant environment in mealtime.
8. Observation evidence of inadequate protein
intake (edema, slow healing, decreased
serum albumin)
5

Monday, June
1st 2015
09.00 am

After 3 x 24 hours of nursing

care , expected patients
reported an increase exercise
tolerance with outcomes:
-

Vital signs in normal

range

IV.

1. Measure the vital signs every 8 hours

2. Observe signs of fatigue (tachycardia,
palpitation, dyspnea, dizziness, blurred firefly, limp, lackluster posture, slow
movements and tense.
3. Provide ROM training
4. Give the HE to the family to assist

Do not complain weak

patients in activities beyond the limits of

and fatigue

tolerance.

IMPLEMENTATION

important to causing anorexia

eliminated
8. Put inadequate protein that causes
a decrease in albumin and other
proteins, edema and slowing
healing.
1. Cardiopulmonary manifestations
of heart and lung efforts to bring
an adequate amount of oxygen to
the tissues
2. Helps determine appropriate
interventions.
3. To prevent contractures
4. To prevent fatigue.

Date/Time

No

Implementation

Dx.

Monday, June

Delegative administration of drugs:

1st 2015
06.00 am

Asam tranexasamat 250 mg (5

Formatif evaluation
The drug was administered through Intra Venous, no
allergic reaction

ml)
09.00 am

1,2

assess the patient's general condition

Weak patients general condition

and vital signs

T : 37 c
P : 80 x/minute
BP : 170/00 mmHg
RR : 24x/minute

09.30 am

Assess etiologic factors from reduced

Patient said that he could not swallow

nutritional intake.

10.00 am

Adjust the semifowler position.

Semifowler position has been given by nurses

10.15 am

Provide the patient drink milk as much

the patient was only able to spend 100 cc

as 100cc through NGT (sonde)

10.30 am

Teach patients to do deep breathing or

breath lips slowly according to ability

Patient cooperative, but has not been able to do well

10.45 am

Provide oxygen therapy 3 lpm

oxygen therapy has been given through nasal canule

12.00 am

1,4

Delegative administration of drugs:

The drug was administered through Intra Venous and oral ,

Cefo Sulbactam 2 gram

Nucral 5 m1 (1 teaspoon)

no allergic reaction

Sign

V.

EVALUATION

No
1

Date
Saturday, June

No Dx
1

Sumatif Evaluation
S : Patient said that he still felt shortness of breath

13th 2015
09.00 am
O : Patients received oxygen therapy 3 l/m through nasal canule
A : The goal has not been achieved
Problem Ineffective Brfoodhing Pattern
P : continue all interventions
2

Saturday, June

S : Patients families said that patient looked weak and pale

O : Hb: 10,8 g/dL, pallor conjungtivals
A : The goal has not been achieved
Problem collaborative anemia
P : continue all interventions

S : Patients families said that patient looked weak

13th 2015
09.00 am

Saturday, June
13th 2015
09.00 am

O : Blood preasure : 170/100 mm/Hg

A : The goal has not been achieved
Problem collaborative hypertension
P : continue all interventions

Saturday, June

13th 2015
09.00 am

S : Patients families said that the patient was able to swallow soft
foods but only spend portion of food
O : Hb: 10,8 g/dL, NGT has been released
A : The goal achieved in part
Problem Imbalanced Nutrition, Less Than Body Requirements
P : continue interventions number 2,3,8

Saturday, June
13th 2015

S : Patients families said that patient looked weak and patient just
lay down on the bed

Sign