Asian Journal of Healthy
and Science
p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol. 3 No. April 4, 2024
Nursing
Care for Mr. K with Chronic Kidney Disease (CKD) in
the High Care Unit (HCU) Room of Gunung Jati Hospital, Cirebon City
Evi Nurmala Fia¹, Dewi Oktaviani2,
Kiki Ameliya3, Rizal Nova Jalaludin4, Erida Fadila5
1,2,3,4,5Institut Teknologi dan Kesehatan
Mahardika, Cirebon, West Barat, Indonesia
Email: enurmalafia@gmail.com1, doktoviiaaa@gmail.com2,
kikiameliyacrb@gmail.com3, rnovajalaludin@gmail.com4, erida.fadila@mahardika.ac.id5
Abstract
Chronic Kidney Disease (CKD) is an impairment of
kidney function that occurs for more than three months in the form of
structural and functional abnormalities of the kidneys with or without a
decrease in the Glomerular Filtration Rate (GFR). Patients with CKD are
increasing every year. West Java is the province that contributes the most
cases of chronic kidney disease in Indonesia, with a prevalence of 0.48%, which
is greater than the prevalence at the national level. The purpose of this case
study is to provide nursing care to patients with CKD. Using a qualitative
approach with case studies as the main method, using observation sheets,
interviews, and documentation studies. The case study selected one patient as
the study subject, namely a patient with CKD in the HCU Room, Gunung Jati
General Hospital, Cirebon City. Nursing care management is based on meeting the
needs of patients carried out in 2 days. The results of the case study showed
that after being given nursing care, there was an improvement in breathing
patterns and a decrease in pain. The conclusion is that the provision of
nursing care is effective in meeting the needs of CKD patients.
Keywords: Nursing
Care, CKD, Chronic Kidney Disease.
INTRODUCTION
Chronic Kidney Disease
(CKD) is a condition of progressive and irreversible kidney function disorders in
that the body fails to maintain metabolism and fluid and electrolyte balance,
which causes uremia (retention of urea and other nitrogen waste in the blood)
Based on the results of
Basic Health Research in 2018, the prevalence of chronic kidney disease in
Indonesia doubled in 2018 compared to 2013
In CKD patients with a
decrease in GFR of 60%, there are still no symptoms, but there has been an
increase in serum urea and creatinine levels
CKD also results in the
emergence of various nursing problems, some of which are acute pain, impaired
gas exchange, ineffective peripheral perfusion, hypervolemia, urinary
elimination disorders, activity intolerance, nutritional deficits, anxiety, and
others. These problems must be addressed immediately so that there is no
decline in health and further complications. Complications that arise due to
CKD include hyperkalemia or excess potassium, pulmonary edema or swelling of
the lungs, acidosis or excess acid in the body, renal osteodystrophy, anemia,
heart failure, and others
The emergence of various
nursing problems in CKD patients causes the emergence of
bio-psycho-socio-cultural spiritual problems. Therefore, CKD patients need to
be given proper nursing care. The role of nurses is very important in caring
for CKD patients, including as health service providers, educators, nursing
care providers, reformers, and health service organizers, especially as nursing
care providers. Nursing efforts that can be made are by maintaining blood
pressure, maintaining and limiting fluid intake into the body, and maintaining
a nutrient intake diet such as low protein, low potassium, and low sodium,
which aims to ease the workload of the kidneys
Based on this data and
information, researchers are interested in conducting a case study by providing
nursing care to patients with CKD to meet patient needs. In accordance with the
background that has been stated, the objectives of this study include being
able to explain the basic concept of nursing care in Mr. K with a medical
diagnosis of CKD in the High Care Unit (HCU) Room of Gunung Jati Hospital,
Cirebon City.
RESEARCH METHODS
This study uses a
qualitative approach with case studies as the main method. The study subject
used was one patient who experienced CKD and continued to receive nursing care
according to standard practice guidelines. The taking of this case was carried
out in the HCU Room of Gunung Jati Hospital, Cirebon City, on April 6, 2024.
The data collection carried out by the researcher in managing this case study
includes interviews, observations, and documentation studies. Data analysis is carried
out from the time the researcher is at the research site during the data
collection until the data is collected. Then, the researcher prepares a nursing
care plan and implements and evaluates the nursing that has been provided to
the patient.
RESULTS AND DISCUSSION
Result
The pre-arrival assessment
in this case is a 93-year-old male patient named Mr. K, admitted to the HCU on
April 5th, 2024, with a medical
diagnosis of CK. The patient first came to the emergency room on April 4th, 2024, with complaints of
shortness of breath, abdominal pain, swollen abdomen, nausea, vomiting,
weakness, difficulty defecating, and lack of appetite. In the assessment on
April 6th, 2024, the patient
experienced complaints of shortness of breath, abdominal pain, and an enlarged
abdomen. The patient's family said that the patient had no history of
infectious diseases or hereditary. Vital sign examination results: blood
pressure (TD): 113/65 mmHg, heart rate (HR): 83x/min, temperature: 36.2 oC,
SpO2: 96%, respiratory rate (R): 25x/min.
A quick and immediate
assessment on April 6th, 2024, was obtained. Airway: shortness of
breath, obstacles to the airway, no additional sounds. Breathing: respiratory
rate: 25x/min, SpO2 96%. Circulation: blood pressure (TD): 113/65 mmHg, heart rate (HR):
98x/min, Glasgow Coma Scale: eye 4, motor 5, verbal
5, 14 (compos mentis), CRT <2
seconds. Installed nasal cannula 5 LPM. Patients receive several drug therapies
in the form of metamizole 2 x 1, omeprazole 2 x 1, mectoclopramide 2 x 1, vit K
2 x 1, zinc 1 x 20 mg, vit D 1 x 1000 mg, tonicard 1 x 1, lactulax 1 x 1. From
the laboratory results, hemoglobin: 12.9 g/dL, hematocrit: 38.1%, erythrocytes
4.32/uL, leukocytes 29,370/uL, lymphocytes 1.1%, monocytes 4.2%, sodium 154.5
mmol/L, potassium 4.97 mmol/L, chloride 114.2 mmol/L, and calcium 8.64 mmol/L.
Renal faal: urea 372.1 mg/dL, creatinine 4.13 mg/dL.
A comprehensive assessment obtained on April 6th, 2024, among others, showed that the patient still looked short
of breath with symmetrical rapid breathing and rapid chest movements. The
patient's respiratory status can be seen as irregular
breathing patterns without any additional sounds, vesicular. Installed 5
liters/minute cannula nassal. Regular pulse circulation status, blood pressure
113/65 mmHg, oxygen saturation 96%, normal heart rhythm, HR: 98x/min.
Neurosensory status obtained by compos mentis awareness with GCS of patient 14, pain assessment obtained by
patients complaining of pain in the abdomen, pain assessment with PQRST
obtained P: pain in the abdomen, Q: quality of pain such as slice, R: location
of pain felt in the abdomen, S: pain scale 4, T: pain felt continuous. The
patient's body temperature was 36.2oC. The
gastrointestinal status is no fluid restriction, and the elimination status of
urine appears yellow with an amount of 500 cc without complaints. Integument:
no complaints, tan skin color, no tenderness, and elastic skin turgor.
Nursing diagnosis is based
on the patient's condition using the Indonesia Nursing Diagnosis Standard (Tim
& SDKI, 2016). There are two nursing diagnoses, namely ineffective
breathing patterns related to obstruction of breathing effort and acute pain
related to physiological injury agents. Nursing diagnosis aims to identify the
response of individual, family, and community clients to health-related
situations
Based on the nursing
action plan that has been made and prepared to overcome the first problem,
namely the ineffective breathing pattern for Mr. K, the action was carried out
according to the plan. Ineffective breathing pattern intervention that has been
prepared in patients includes monitoring breathing patterns, monitoring breath
sounds, frequency, rhythm, and breathing effort, monitoring oxygen saturation,
adjusting respiratory monitoring intervals according to the patient's
condition, positioning semi-fowlers or fowlers, and providing oxygen if needed.
The implementation of nursing was carried out to overcome the problem of
ineffective breathing patterns in Mr. K by monitoring breathing patterns,
breathing sounds, frequency, rhythm, depth, and effort of breathing, monitoring
oxygen saturation, documenting monitoring results, and administering oxygen.
Based on the nursing
action plan that has been made and prepared to overcome the acute pain problem
in Mr. K, the action is carried out according to the plan. Interventions for
acute pain treatment that have been prepared for patients include identifying
the location of pain, characteristics, duration, frequency, quality, and
intensity of pain, identifying pain scales, identifying factors that aggravate
and alleviate pain, controlling the environment that aggravates pain,
explaining pain relief strategies, advocating independent pain monitoring, and
collaborating by providing analgetics if needed. The implementation of nursing was
carried out to overcome acute pain problems in Mr. K by identifying the
location of pain, characteristics, duration, frequency, intensity, and scale of
pain, as well as identifying factors that aggravate and alleviate pain.
The
evaluation found on Mr. K after being treated for 2x24 hours on April 7th, 2024, the problem of ineffective breathing patterns
related to obstruction of breathing effort has been resolved, in accordance
with the planning criteria, namely, the patient's breathing pattern improved,
and the intervention is stopped. Likewise, the evaluation found on acute pain
problems related to physiological injury agents was resolved in accordance with
the planning criteria, namely that the patient's pain was reduced, and the
intervention was stopped.
Discussion
Ineffective
Breathing Patterns
In this case, it was found that the
patient's complaint was that he seemed to be short of breath. This is in
accordance with the opinion of
There is no gap
in the diagnosis of effective breathing patterns because, according to
Shortness of
breath can also occur due to a decrease in nephron function, which results in
irreversible kidney disorders so that it is unable to secrete acid, which
results in metabolic acidosis. Where acid secretion, ammonia secretion, and
sodium and bicarbonate absorption decrease, so fluid and sodium retention
occurs because the kidneys are unable to concentrate or dilute urine normally
in end-stage kidney disease. This disorder has an impact on hydrostatic
pressure in the body, as a result of which there will be a buildup of fluid in
the lungs, especially in the alveoli, which are important organs for carrying
out the respiration process
Based on the planning of Mr. K, the actions
that will be taken are in accordance with the intervention that the researcher
has prepared for the problem of ineffective breathing patterns SLKI SIKI
(2017). The intervention was carried out on Mr. K with the aim that after
nursing treatment for 2 x 24 hours, it is hoped that the breathing pattern will
improve and the problem will be resolved with the outcome criteria: shortness
of breath/dyspnea decreased, breathing frequency improved. The action plan in
respiratory monitoring includes observation: monitoring the frequency, rhythm,
and effort of breathing. Monitoring breathing patterns, monitoring oxygen
saturation, therapeutics: positioning the semi-fowler or Fowler; setting the
respiratory monitoring interval according to the patient's condition;
documenting the monitoring results; education: informing the monitoring
results; collaboration: administering oxygen.
One of the actions that can be carried
out in patients is oxygen therapy through the nasal cannula. According to Roca
in
Acute Pain
In this case, it was found
that Mr. K's patient complained of pain in the abdomen, like a slice with a
scale of 4 that was felt continuously, accompanied by an enlarged abdomen. The
established diagnosis is acute pain related to physiological injury agents. At
the time of the subjective data review, the patient said that the pain in the
abdomen and abdomen was enlarged. Objective data was obtained from pain scale
data and facial expressions that appeared to be grimacing in pain. This is in
accordance with the major signs obtained from the diagnosis of SDKI (Indonesia
Nursing Diagnostic Standard)
According to the
researcher, there was no gap in pain diagnosis because, in the physical
examination of pain comfort in patients, pain assessment with PQRST was
obtained by patients who said P: pain in the abdomen, Q: pain quality like
slice, R: location of pain felt in the abdomen, S: pain scale 4, T: pain felt
continuously in accordance with the opinion of Alatas (2017), who explained
that pain in the abdomen felt by CKD patients could be caused by a buildup of
fluid in the abdomen (ascites). If a large amount of fluid continues to
accumulate, it will cause shortness of breath. This is marked by an increase in
the size of the abdomen in patients, strengthened by Marfuah's theory (2018),
which states that CKD patients are recommended to limit the intake of incoming
fluids so that fluid buildup does not occur, which can cause decreased heart
and lung function.
Based on the planning Mr.
K, the implementation of interventions carried out in accordance with the acute
pain measures that have been prepared for patients is in accordance with SIKI
(Indonesia Nursing Intervention Standards), and the application and writing of
outcome criteria in patients are in accordance with SLKI (Indonesia Nursing
Output Standards). According to SIKI (Indonesia Nursing Intervention Standard)
and SLKI (Indonesia Nursing Output Standard) which are used to diagnose acute
pain with the aim that after nursing treatment for 2 x 24 hours, it is hoped
that the pain level will be reduced and the problem will be resolved, the
outcome criteria: pain complaints decrease, restlessness decreases, pulse
frequency improves, breathing patterns improve. Action plans in pain monitoring
include observation: identifying the location, characteristics, duration,
frequency, and intensity of pain; identifying pain scales, identifying factors
that aggravate and alleviate pain; therapeutics, controlling the environment
that aggravates pain, documenting monitoring results; education: informing
monitoring results, teaching non-pharmacological techniques to reduce pain,
collaboration: providing analgetics if needed.
One of the actions that
can be carried out is non-pharmacological therapy with deep breath exercises.
This technique is a form of deep breath relaxation that can increase the
dilation of the lungs so that their development becomes optimal and the muscles
relax. Deep breathing exercises can maximize the amount of oxygen flowing and
supplying tissues, allowing the body to produce energy and reduce fatigue and
pain
CONCLUSION
Nursing problems in
patients are ineffective breathing patterns and acute pain. The implementation
of nursing actions in this case was carried out in accordance with the
diagnosis that was established, the nursing intervention that had been made,
and the data analysis of the needs of patients with chronic kidney disease
(CKD). After the implementation of nursing to Mr. K with CKD for 2 x 24 hours,
and the final result of the nursing process is an evaluation of the nursing
care provided. In the evaluation, there were two
nursing diagnoses that had been resolved as planned and the intervention was
stopped.
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Copyright holders:
Evi Nurmala Fia, Dewi Oktaviani, Kiki
Ameliya, Rizal Nova Jalaludin, Erida Fadila (2024)
First publication right:
AJHS -
Asian Journal of Healthy and Science
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