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com

A. Assessment
1. Biodata
a. Name : Mr.Sudaryo
Gender : Man-man
Age : 78
Education : SD
Occupation :Farmer
Religion :Islam
Address : RT/RW 03/06Pandegan, Majenang, Cilacap, Central Java
Medical diagnosis : CKD
Admission date : November 11, 2024
Assessment Date : November 13, 2024
Register no : 494945

b. Responsible person
Name : Mr. Eru
Gender : man
Age : 64
Education : SD
Occupation :trader
Religion : islam
Address : The same

2. Health History
a. Complaints upon admission to the hospital:
Pain in the legs, can't walk
b. Complaints during assessment:
During the assessment on November 13, 2024, the client complained of lower
back pain that radiated to the right leg, and the patient complained of difficulty
moving the right leg, the client also complained of nausea and looked weak. The
family said the patient had not eaten for 10 days, and only ate 1-2 spoons. The
patient looked restless and avoided pain, the patient grimaced when the leg was
moved. The patient also said the pain decreased after being given medication. The
patient's muscle strength decreased so that activities were assisted by the family.
P: The pain feels worse when moving.
Q: The patient said the pain felt like being stabbed.
R: waist that extends to the right leg
S : scale 5 from range (1-10)
T : when moved
c. Current health history
The patient complained of lower back pain that spread to the right leg, the client
complained of nausea and appeared weak.
d. Past health history
The family said the patient had no history of similar illnesses before.
e. Family Health History
 The family said the family did not have a disease similar to the patient's.
3. Function pattern
Activity At home In the hospital
Nutrition
a. Eat
- Types of food Rice, vegetables, fish Porridge (RP diet)
- Frequency 2x a day 3x a day
- Taboos There are no taboos There are no restrictions
- Dietary habit 1 serving 2 spoons
- complaint No problem Unable to finish food,
b. drink anorexia
- types of drinks Water + coffee
- frequency 5-6 glasses Water
- amount +_ 1000 cc 4-5 glasses
- taboo There are no restrictions +_ 900cc
- complaint No complaints There are no restrictions
No complaints
Fecal elimination
- frequency 1x a day Not yet pooped
- pattern Normal Abnormal
- consistency Mushy -
- smell Typical feces -
- color Typical feces -
- amount +_ 90cc -
- problem No problem No desire to defecate
Urinary Elimination
- frequency 3-4x a day 2-3x a day
- pattern Normal Normal
- color Yellow Deep yellow
- amount Not reviewed +_900cc
- problem No problem Catheter in place

Rest and sleep

a. Evening
- pattern Normal Abnormal
- number of hours 8 hours More than 8 hours
- sleeping habits Not reviewed The lights are not turned
- difficulty sleeping There is no difficulty off
b. Afternoon Constantly restless
- pattern Normal
- number of hours 1-2 hours Abnormal
- sleeping habits There is no habit More than 2 hours
- difficulty sleeping There isn't any There isn't any
There isn't any
Daily activities
- activity Independent Assisted
- type of activity Gardening -
- habit Sit Sit and lie down
Personal hygiene
 a. bathe 2x a day 1x a day
b. brush your teeth 2x a day Not reviewed
c. shampoo 1x a day Do not wash your hair
d. cut nails Not reviewed while in the hospital
e. problem No problem Haven't cut your nails yet
Assisted by family

4. physical examination
a. general condition: compos mentis
b. vital signs
- BP : 140/90
- RR : 13x/minute
- Temperature: 36.6
- Pulse: 62x/minute
- Spo : 92

c. BB/TB
- Weight: 60 Kg
- Height : +_ 165 cm

d. Head to Toe
1) Head: oval head shape, thin hair, black with gray hair
2) Eyes: anemic conjunctiva, no signs of inflammation, icteric sclera
3) Nose: symmetrical and clean shape
4) Ears: right and left ears are symmetrical, clean
5) Lips & mouth: the shape of the lips is not symmetrical, clean, the oral mucosa
is moist, there are white spots on the tongue.
6) Neck: no swelling of the thyroid gland
7) Thorax: symmetrical chest shape, normal breathing rate, slow breathing
rhythm, vesicular breath sounds.
8) Abdomen: symmetrical abdominal shape, there is mild ascites, there are
tympanic sounds and there are bowel sounds, there is tenderness
9) Genitalia: normal, no signs of inflammation, urinary catheter installed
10) Anus: no problems in the anus area
11) Upper extremities: right and left hands are symmetrical, IV line installed in the
right hand
12) Lower extremities: right and left legs symmetrical, no edema, right leg hurts
when moved
13) Skin: brown skin color, patient's body feels warm, skin turgor is not elastic,
CRT <3 seconds

5. Psychosocial data
a. Psychological
The client said he felt a little uncomfortable and restless.
b. Social
Before being sick, the client said he could socialize well, but the client was less
able to socialize well in the hospital.
6. Spiritual data
The patient is a Muslim, but when he is sick, the client has difficulty in carrying out
his religious duties.

7. Supporting investigation
a. Laboratory
Indicator, result, unit, normal value
b. USG
R/USG Abd (+), Results (+), anterior collection of right kidney media, multiple
left nephrolithiasis < 12 m, chronic cystitis

8. Therapy program
Type of drug, dosage, method

9. Data analysis
Data Etiology Problem

DS ; Ckd Acute pain D.0077

- The patient
complained of pain Tubular damage
in the waist, which Disorders of absorption,
spread to the right secretion, excretion
leg. function
- The patient said the
pain was like being Accumulation of toxic
stabbed. metabolites
DO
- The patient appears Uremia
to wince when the
leg is moved. Neuromuscular disorders
- The patient appears
restless Irritation of the sensory
- The patient appears nerves
to be avoiding pain.
- BP : 140/90 Muscle pain

Acute pain
Ds Ckd Nutritional deficit
- The patient D.0019
complained of Uremia
nausea
- The family said the GI disorders
patient had not
eaten for 10 days. Acid imbalance disorders
- The family said the
patient only ate 1-2 Gastric irritation
spoonfuls of food.
 Stomach acid rises
Do: The patient's
swallowing muscles appear Nausea and vomiting
weak.
Uremia 158 Nutritional deficiencies
Creatinine 4.8 less than body
requirements
Ds Ckd Impaired physical
- The family said the mobility
patient's activities Neuromuscular disorders D.0054
were assisted by the
family Muscle loss
- The patient
complained of Changes in the
difficulty moving musculoskeletal system
his right leg.
Do Impaired physical
- The client's muscle mobility
strength appears to
have decreased.
- The patient appears
weak

10.
B. Formulation of nursing diagnoses based on priorities
1. Acute pain related to physiological agents (inflammatory) is characterized by
2. Nutritional deficits related to reluctance to eat are characterized by
3. Impaired physical mobility related to neuromuscular disorders is characterized by
 C. Nursing planning, implementation and evaluation
No Nursing diagnosis Planning Implementation Evaluation
Objective Intervention Rational
1. Acute pain After nursing Pain management 1. assist in making November 13, 2024 S:
intervention for 1x24 (I.08238) more informed 16.00 -the patient said the
hours, it is expected Observation decisions pain reduced after
that the pain level will 1. Identification of regarding pain 1. Identifying pain being given the
decrease with the location, management, as 2. Check BP, medication
following outcome characteristics, well as temperature,
criteria: duration, monitoring pulse, Spo, RR O:
1. Complaints of frequency, changes in the 3. Ask the patient - The patient
pain decreased intensity of pain patient's what the side still looks
2. Anxiety 2. Identification of condition over effects are of the restless
decreases pain scale time. medication that - The patient
3. Monitor side 2. evaluate the has been given. still appears
effects of effectiveness of 4. Provide to be
analgesic use the pain treatment analgesics avoiding the
Therapeutic provided and (tramadol 1 painful area.
1. Providing determine amp) - BP : 140/90
norpharmacolog whether the - Spo : 92
ical techniques, intervention - N : 62
deep breathing needs to be - RR :
relaxation adjusted. 13x/minute
techniques 3. to prevent - S : 36.6
2. Facilitate rest complications A:
and sleep and ensure Acute pain
Education patient safety. Q:
1. Teach non- With proper Continue
pharmacological monitoring, side intervention
techniques effects can be
 Collaboration managed
1. Collaboration in effectively.
providing 4. can help reduce
analgesics levels of anxiety
and stress
associated with
pain.
5. Adequate rest and
sleep are essential
for the healing
process and
reducing pain
perception.
6. Providing patients
with education
about non-
pharmacological
techniques such as
deep breathing
relaxation or
visualization
techniques can
empower patients
to manage pain
independently.
7. To reduce patient
pain quickly
2. Nutritional deficit After nursing Nutrition management 1. to find out November 14, 2024 S:
intervention for 1 x (I.03119) whether patients 09.45 - patient
24 hours, it is Observation are getting the complains of
expected that 1. Identification of amount and type 1. check patient's nausea
nutritional status will nutritional status of nutrition that BMI - The family
 improve with the 2. Identifying food suits their body's 2. ask if there are said the
following outcome allergies and needs. any allergies and patient still
criteria: intolerances 2. to prevent adverse to what extent had not
1. The portion of 3. Monitor food or even dangerous the patient can eaten.
food intake reactions due to eat o:
consumed Therapeutic consuming certain 3. monitor patient - the patient
increases 1. Provide low foods food intake looks weak
protein foods 3. to ensure that 4. provide low - td : 145/100
Education patients meet their protein food - N : 136
1. Teach calorie and 5. teach a - RR :
programmed nutritional needs programmed 15x/minute
diet appropriate to diet - Spo : 94
their condition. - S : 36.4
4. can help reduce A:
the burden on the Nutritional deficit
kidneys and Q:
prevent further Continue
damage. intervention
5. so that patients
understand the
goals and benefits
of the diet
3. Physical Mobility After nursing Mobilization support 1. to determine the November 15, 2024 S:
Disorders intervention for 1x24 (I.05173) extent to which the 09.45 - The family
hours, it is expected Observation patient can said the
that physical mobility 1. Identify the perform physical patient's
will increase with the presence of pain activities, including 1. identify the activities
following outcome or other physical movement and patient's pain were still
criteria: complaints mobilization. and whether assisted by
1. Increased 2. Identify 2. to find out how far there is any the family
extremity physical the patient can other pain O:
movement tolerance for perform physical 2. identify the - the patient's
movement activity without extent to which muscle
 3. Monitor general causing fatigue or the patient can strength is
conditions injury. perform still weak
during 3. to identify signs of activities - the patient
mobilization physical stress or 3. monitor the looks weak
Therapeutic complications such patient's general - TD : 150/135
1. Facilitate as hypotension, condition when - N : 112
movement dizziness, or being taught to - Spo : 94
2. Involve the excessive fatigue. sit - RR :
family to help 4. can help patients 4. involving the 23x/minute
the patient to gradually family to help - S : 36.9
improve increase their the patient A:
mobility. mobility improve Impaired physical
Education 5. can help patients movement such mobility
1. Explain the feel more secure as tilting right
purpose and and supported, and tilting left P
procedures of and increase 5. teach simple Continue
mobilization motivation to mobilization intervention
2. Teach simple mobilize. such as sitting in
mobilizations to 6. to increase their bed
be done such as understanding of
the benefits of
sitting in bed.
mobilization in the
healing process.
7. can prevent
complications
related to
immobility, such as
blood clots, muscle
contractures, or
decubitus
problems.
D. Progress notes
Day/date Progress notes Initial / name
Wednesday, November 13, 2024 S
- The patient complained that the pain
was still there.
- The patient said the pain decreased
after being given medication.
- The patient complained of nausea
- The family said the patient still had
not eaten.
- Activities are still assisted by family
O
- The patient appears restless
- The patient still appears to be
avoiding pain.
- BP : 140/90
- Spo : 92
- N : 62
- RR : 13x/minute
- S : 36.6
A
Problem partially resolved
P
Continue intervention
I
pain management
Identify the scale of pain felt
Teaching deep breathing relaxation
techniques
Providing analgesic therapy
 Nutrition management
1. monitor patient food intake
2. provide low protein food
mobilization support
1. monitor the patient's general
condition when moving
2. involving the family to help the
patient improve movement such as
tilting right and tilting left

E
Problem partially resolved, continue
intervention

Thursday, November 14, 2024 S

- The patient still complains of pain
- The patient complained of increasing
pain.
- The family said the patient ate only
1-2 spoons.
- Activities are still assisted by family
O
- The patient appears restless
- The patient appeared to wince when
moved.
- Increased pulse rate
- TD : 145/100
- N : 136x/minute
- RR ; 15x/minute
A:
Problem not resolved
P
 Continue intervention
I
pain management
Teaching deep breathing relaxation
techniques
Providing analgesic therapy

Nutrition management
3. monitor patient food intake
4. provide low protein food
mobilization support
3. monitor the patient's general
condition when moving
e
problem not resolved, continue intervention

Friday, November 15, 2024 S

- the patient still complains of pain
- family said to eat still 1-2 spoons
- family said activities are still assisted
by family
o
- the patient still looks restless
- the patient looks weak
- TD : 150/135
- N : 112
- Spo : 94
- RR : 23x/minute
- S : 36.9
A
Problem not resolved
 P
Continue intervention
I
pain management
Identify the scale of pain felt
Teaching deep breathing relaxation
techniques
Provide analgesic therapy by increasing the
dose

Nutrition management
5. monitor patient food intake
6. provide low protein food
mobilization support
4. monitor the patient's general
condition when moving
5. involving the family to help the
patient improve movement such as
tilting right and tilting left
E
Problem partially resolved, continue
intervention

E.