NURSING CARE PLAN CLIENT Mrs. X
With:
FLUID AND ELECTROLITE REQUIREMENT PROBLEM
At MARDI WALUYA HOSPITAL, BLITAR
By:
GROUP 1
1.
ILUS FEDIASTARI (12013000003)
2.
RIRIN FATIMATUS (12013000020)
3.
TITAK ABETNEGO (12013000018)
HEALTH MINISTRY Of REPUBLIC INDONESIA
HEALTH
POLYTECHNIC Of MALANG
NURSING
MAJORS
STUDY PROGRAM DIPLOMA III NURSING Of BLITAR
2014
NURSING CARE
PLAN
A.
NURSINGASSESSMENT
a.
Biodata
1)
Name : Mrs. X
2)
Gender : Woman
3)
Age : 40 years old
4)
Marrital status ; Married
5)
Job : Housewife
6)
Religion : Islam
7)
Education : Senior High School
8)
Address : Sawentar village, Kanigoro, Blitar
Regency
9)
Date of
Hospitalization : 16 April 2014
b.
Medical Diagnosis : Cronic Kidney Failure
c.
Especial Sigh :
Client tell, she feel thirsty
d.
Disease History (now)
Client tell that before hospitalization
she often fell lowback pain, headache, decreasing urine frequency.
e.
Disease History (past)
Client have hypertension since 5 years
ago and she always consume anti-hypertension agent, ex; captopril. amlodipine
f.
Family health history
Client tell that her family have
Diabetes Mellitus history
g.
Pattern of Daily Activity
1)
Eating and
Drinking Pattern
Before Hospitalization: Client tell
about, she eating each 3 times/day; menu rice, soup, and tofu. Always drinking
tea in the morning.
Hospitalization; she eating each 3
times/day; menu rice, soup, and tofu. Always drinking mineral 3 times/day.
2)
Elimination
Pattern
Before Hospitalization: Client tell
about Alvi elimination 1 times a day. Urinal elimination about 2 times a day.
Hospitalization: Client tell about alvi
elimination each 1 times for 2 day. Urine elimination 2 times a day
3)
Sleep and Rest
Pattern
Before Hospitalization; Client tell
about sleep 5 hours a day.
Hospitalization; Client tell about sleep
6 hours a day
4)
Hygiene Pattern
Before Hospitalization: Client tell
about take a bath 2 times a day. Brush teeth 2 times a day. And cutting nails 1
times each a week.
h.
Psychosocial History
The hospitaClient oppen mind when
anamnese process. Interaction between client and family is good. When
hospitalization, client says that she feel comfort, because her son always
caring the client in the hospital.
i.
Physical Examination
1)
Generality:weak.
Consiousness level; Compos Mentis
2)
Vital Signs:
BP: 150/100 mmhg
HR; 91 times / minutes
T; 37° C
RR;
24 times/minute
Weight;
55 kg’s
Height;
15 cm’s
3)
Head and Neck
Examination: Black Hair; Clean Cephal-skin; No hairfall; No flea
4)
Integument
Assessment: there is no Ducubitus/Depressing pain; Decreasing skin Turgor:
Dryskin
5)
Chest and
Thorax: Inspect:Simetris; Palpat:No abnormal bump; No pain depress when
palpationed.Auscult: No murmurs Percussion: Sonor
6)
Breast:
Simetris; No abnormal bump; Uppermost milk nipple: No chafed
7)
Abdomen;
Inspect:Simetris, clean; Palpat:No abnormal bump; No pain depress No pain
depress when palpationed.Auscult: Intestine noise; 5 times/minute Percussion:
Tympani
8)
Genetalia;
Clean; No abnormalities sign; No lession
9)
Extremity: client tell fatigue. Muscle tonus
4 4
4 4
j.
Neurologycal Assessment
GCS : E;4 V:4 M:5
k.
Diagnostic Examination
Blood: GDA 16 April 2014; 250 mg/dl
Hb:
6,5 g/dl
Leukosit:Segment:90%
Urine: Volume:350mL/24 hours
Colour:
Disturbed & Thick Concentrated
Ro(BJ):
1.011 g/mL
Osmolality: 300 mOsm/kg
Natrium: 45
mEq/L
Protein: 4+
Ureum: 93 mg/dl
Kreatinin: 9,62 mg/dl
l.
Therapy/ Medicine
Oral; Modify mediceni according renal function
CaCO3
tab 3x1
Clonidin tab 3 x 1
Nifedipine tab 3 x 1.
Injection;
Ranitidin 1
Amp/12 Hours, Inj. Metochlorpamid 1 Amp/8 hours
Fluid
Therapy:Optimizing and maintain the
balance of fluids and salts
Diet;
High Calories, Low proteine
Blitar, 16 April 2014
Perawat
KELOMPOK
2. DATA ANALYSIS
DATA
ANALYSIS
Name: Ny. X
Age: 40 years
Register: 01
|
DATA
|
PROBLEM
|
ETIOLOGY
|
|
Subjective:
-Client fell thirsty
-Client fell headache
-Client fell fatigue
-seldon urinate
-Often fell pain in lowback pain
Obyective:
1)
Generality: Weak
Level of awarenes:CM
2)
Vital Sign
BP: 150/100mmHg
HR:91x/min
T;37C
weight:55kg
heigt:155cm
3)
Decreasing Skin turgors, Dry
skin
4)
Diagnostic:
-Blood: GDA
at 16 April 2014: 250 mg/dl
Hb: ^,5g/dL
Leukosit:Segmen:90%
-Urine
Volume:350ml/24hours
Colour:
Disturbed7Thick Contentrated
BJ:1011g/ml
Osmolality:300mOsm/Kg
Na:45mEq/L
Protein:4+
Ureum;93mg/dl
Creatinin:9,62mg/dl
5)
Muscle
Tonus
4 4
4 4
6)
GCS E:4 V:4 M:5
|
Deficient Fluid Volume
|
Regulatory Mechanism Failure
|
B.
NURSING DIAGNOSIS
Room :01
Name :Ny. X
Umur :40 years
Register:01
Nursing Diagnosis:
Deficient Fluid Volume Related to Regulatory
Mechanism Failure
NURSING CARE PLAN
Name; Ny. X
Reg. :01
|
DATE
|
No. DX
|
NURSING
DIAGNOSIS
|
GOAL
STANDART CRITERIA
|
INTERVENTION
|
RATIONALE
|
TT
|
|
16 April 2014
|
01
|
Deficient Fluid volume related toRegulatory
Mechanism Failure
|
After doing the nursing action during 2x24 hours
fluid balancing at client became normal.
|
INDEPENDENT NURSING
CARE
-Built Trust relation with patient.
-Monitor Vital Signs(BP:RR;HR;T;awareness
examination)
-Monitor urine output
-Measure daily client weight and arrange fluid
input each 24 hours
-Monitor perifer pulse, capilarry refill, skin turgor,
and mucosa membrane
-Monitor input and output, Note urine BJ
-Give Health education to the patient and family
about their disease
COLABORATION
-Give
IV solution based on indication
(ex:isotonic fluid: NaCl 0,9%. Dextrose/Water 5%)
-Give Oral, Injection, and Diet Therapy
|
-Trust relation with patient can make the nurse easier
to do nursing intervention.
-Hypovolemiacan manifested by hipotension and tachicardia.
-Changing Fluid Requirement based on lossing fliud
persistend
-Changing of weight not accurately get impact to
intravascular volume
-There is some indicator from dehidration levels,
or adequate circulaton volume.
-Give estimate of changing fluid requirement,
renal function, and efectivity of therapy
-Health Education can increase client knowledge
about disease.
-Cristaloin repairs circulation, altough advantage
only temporary
-Giving Therapy support of balancing acid and basa
fluid
|
|
D.
IMPLEMENTATION
NURSING NOTE
Room : 01
Name patient : Ny. X
Age : 40 years
No. Register : 01
|
NO
|
NO. DX
KEP
|
DATE
|
TIME
|
ACTION
|
SIGNATURE
|
|
1.
|
01
|
16 April 2014
|
08.00
09:30
10:00
10:15
10:30
10;45
11:00
\
13;00
|
-
Build a trusting relationship with clients.
-
Vital signs monitoring
BP: 150/100 mmHg
HR: 91x/minute
T: 37° C
RR: 24 x/minute
weight: 55kg
height: 155 cm
-
Monitor urine output
Since the morning after
waking up, urination clients
with a volume of 100 mL
-
Measure weigh the client
Weight 55kg clients
-
Assess peripheral pulses, capillary refill, skin turgor, and mucous
membranes
-
Taking urine and blood samples.
-
Provide Ivsulution, isotonic solution of NaCl 0.9%
-
Provide therapies
Tx Oral:
CaCO3 tab 3
x 1
Clonidin tab 3 x 1
Nifedipine tab 3 x 1
Tx injection:
Injection Ranitidin 1 Amp/12 hour, Injeksi Metochlorpamid 1
Amp/8 hours
Tx fluid:
Optimizing and maintain
the balance of fluids and salts
ssTx Diet:
A diet high in calories and low in protein
|
|
E.EVALUASI
FORMATIVE
EVALUATION
NAME : Ny. X
AGE : 40 years
|
No. Dx
|
Date
|
Evaluation
|
|
01
|
16 April 2014
(at 20.00)
|
S:
-
Clients say that decreasing feel thirsty
-
Client said that did not feel dizzy and reduced pelvic
pain
-
Clients say the body feels more
fresh and feeling
weak reduced
O:
01) General state : the condition better
02) Awareness compos mentis
03) Vital signs
BP: 120/80 mmHg
HR: 75/minute
T: 37° C
RR: 21/minute
Weight: 55 kg
Height: 155 cm
04) increased skin turgor, Skin looks more moist
05) investigation
-
Darah
·
GDA: 160 mg/dL
·
Hb: 12.1 g/dL
-
Urine
Ø Urine Volume: 450mL (05.00-08.00)
Ø Urine colour: yellowish white, not concentrated
Urine Specific Gravity: 1.0250 g / mL
Ø Natrium: 40 mEq/L
Ø Ureum: 40 mg/dL
Ø The strength of muscle tone
5 4
 5 4
06) GCS : E: 4 V:4 M:5
A: Problem of Deficient
Fluid Regulatory solved , but still there is
the possibility of a risk of lack of fluids.
P: The intervention was stopped,
followed by interventions to regulate fluid
balance client
|
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