STUDENT’S PERSONAL PROFILE

Nama :Wuisan, Angelina Tesalika

Kelamin :Perempuan

Tanggal Lahir :16 Januari 2002

Program :Keperawatan

Tingkat / Semester :2/4

Paralel :A

Photo

Tanda Tangan,

(......................................)
FORM “D” Adult Assessment Case
REPORT OF PRACTICAL EXPERIENCE
MEDICAL SURGICAL NURSING PRACTICE II

I. Demographic Data
Pt. Name : Pasien a
Room/ Bed # :-
Medical Record # : diabetes mellitus
Age :58 year(s)
Gender : male female
Marital status : single married divorced
Address : Jl. Prof. Soemantri Brodjonegoro No.1
Occupation : indonesia
Religion :-
Medical Diagnosis : Diagnosa gagal ginjal kronik stadium V ec.
Nefropati diabetes + Diabetes Melitus tipe 2 + Hipertensi grade I + Ulkus diabetikum
Physician Name : dr. Sandra Rini, S.Ked.

II. Definition of Disease** (must be with at least four definition and four references)
Gagal ginjal kronik ditandai dengan adanya gangguan fungsi ginjal dan penurunan progresif dan
irreversible dari laju filtrasi glomerulus (GFR). Gagal ginjal kronik telah menjadi masalah
kesehatan dunia.
1 Prevalensi gagal ginjal kronik di seluruh dunia sebesar 8 – 16%.
2 Penyakit ini bukan hanya menyebabkan masalah kesehatan tetapi juga menimbulkan masalah
ekonomi. Di Amerika Serikat setiap tahunnya dibutuhkan biaya $49.3 juta untuk pengobatan
GGK.
3 Komplikasi dari gagal ginjal kronik adalah penurunan kognitif, anemia, gangguan tulang dan
mineral hingga kematian. Dimana diabetes mellitus merupakan penyebab utama dari gagal ginjal
di dunia.

Penyakit ginjal kronik (Chronic Kidney Desease) adalah keadaan dimana terjadi penurunan fungsi
ginjal yang cukup berat secara perlahan – lahan (menahun) disebabkan oleh berbagai penyakit ginjal.
Peyakit ini bersifat progresif dan umumnya tidak dapat pulih kembali (irreversibel). Gejala penyakit
ini umumnya adalah tidak ada nafsu makan, mual, muntah, pusing, sesak nafas, rasa Lelah, edema
pada kaki dan tangan serta uremia. Apabila nilai Glomerulo Filtration Rate (GFR) atau Tes Kliren
Kreatinin (TKK) < 25 ml/menit, diberikan Diet Rendah Protein (Almatsier, 2004).

Reference(s): 1. Levey AS, Coresh J. Chronic Kidney Disease. Lancet. 2012; 379(9811):165-80. 2. Jha V, Garcia G,
Iseki K, Li Z, Naicker S, Plattner B, Saran R, Wang AY, Yang CW. Chronic Kidney Disease: Global Dimension and
Perspectives. Lancet. 2013; 382(9888): 260-72.
III.Etiology* must be with at least four references

- Perokok aktif
- Etiologi memegang peran penting dalam memperkirakan perjalanan klinis Gagal Ginjal
Kronik (GGK) dan penaggulangannya. Penyebab primer Gagal Ginjal Kronik (GGK) juga
akan mempengaruhi manifestasi klinis yang akan sangat membantu diagnose, contoh: gout
akan menyebabkan nefropati gout. Penyeban terbanyak Gagal Ginjal Kronik (GGK) dewasa
ini adalah nefropati DM, hipertensi, glomerulus nefritis, penyakit ginjal herediter, uropati
obstruki, nefritis interstitial. Sedangkan di Indonesia, penyebab Gagal Ginjal Kronik (GGK)
terbanyak adalah glomerulus nefritis, infeksi saluran kemih (ISK), batu saluran kencing,
nefropati diabetic, nefrosklerosis hipertensi, ginjal polikistik, dan sebagainya (Irwan, 2016).

Reference(s): . Sharad P. Pendsey. Understanding Diabetic Foot. Int J Diabetes Dev Ctries. 2010; 30(2): 75–9 .

IV. Signs and Symptoms

Signs and Symptoms Theoretical Practical

Tekanan darah tinggi.

Perubahan frekuensi dan

jumlah buang air kecil dalam
sehari

Adanya darah dalam urin.

 Lemah serta sulit tidur.

Kehilangan nafsu makan.

Reference(s):

V. Pathophysiology* (Chart) must be with at least four references

Patofisiologi penyakit ginjal kronis berupa kerusakan ginjal yang direpresentasikan oleh penurunan
laju filtrasi glomerulus yang berujung pada berbagai komplikasi.

Ginjal normal memiliki 1 juta nefron (unit satuan ginjal) yang berpengaruh terhadap laju filtrasi
glomerulus. Ginjal memiliki kemampuan untuk menjaga laju filtrasi glomerulus dengan
meningkatkan kerja nefron yang masih sehat ketika ada nefron yang rusak. Adaptasi ini
menyebabkan hiperfiltrasi dan kompensasi hipertrofi pada nefron yang sehat. Hipertensi dan
hiperfiltrasi pada glomerulus merupakan faktor yang berpengaruh besar dalam progresivitas penyakit
ginjal kronis

Laju aliran darah ke ginjal berkisar 400 mg / 100 gram jaringan per menit. Laju ini lebih banyak
dibandingkan dengan aliran ke jaringan lain seperti jantung, hati dan otak. Selain itu, filtrasi
glomerulus bergantung pada tekanan intra dan transglomerulus sehingga membuat kapiler
glomerulus sensitif terhadap gangguan hemodinamik

Peningkatan dasar plasma kreatinin dua kali lipat kurang lebih merepresentasikan penurunan laju
filtrasi glomerulus sebanyak 50%. Contoh: plasma kreatinin dasar senilai 0.6 mg/dL yang meningkat
menjadi 1.2 mg/dL, (masih dalam batas normal), menggambarkan terdapat 50% kerusakan massa
nefron[2].

Peningkatan tekanan kapiler glomerulus dapat menjadi cikal bakal glomerulosklerosis fokal dan/atau
segmental yang kemudian dapat berakhir menjadi glomerulosklerosis global. Membran filtrasi
glomerulus memiliki muatan yang negatif, sehingga membuat hal tersebut menjadi penghalang dari
makromolekul anionik. Dengan penghalang elektrostatik ini, protein pada plasma dapat menembus
filtrasi glomerulus
References:

VI. Assessment
A. Health History
1. Chief Complaints
2. History of Present Illness

3. Past History
a. Childhood Illness : diabetes mellitus sejak 10 tahun

b. Accident(s)
i.Type :
ii.Date/month/year :

c. Allergy :

d. Hospitalization(s)
i.Cause(s) : Nefropati diabetes + Diabetes Melitus tipe 2 + Hipertensi grade I + Ulkus diabetikum
ii.
iii.Date/month/year :

e. Medications : Terapi medikamentosa berupa cairan intravena IVFD NaCl 0,9 % X TPM, Captopril 2
x 12,5 mg, Furosemid Injeksi/ 8 Jam, asam folat 2 x 1 mg dan Glimepiride 1 x 2 mg

4. Family History (3 Generations Genogram)

Legend:

=Female
= Male

= Dead Female

= Dead Male
= Pt (male)

= Pt (female)

= Divorced

= Twin
= Adopted
 5. Lifestyle

LIFESTYLE PAST PRESENT

Diet Pattern

 Food Amount : Amount :

Frequency : Frequency :

Contents : Contents :

Others (specify): Others (specify):

Nursing Dx. Imbalanced Nutrition : More than body requirements

Imbalanced Nutrition : Less than body requirements

Others : ____________________________________________________________________________

 Liquid Amount : Amount :

Frequency : Frequency :

Contents : Contents :

Others (specify): Others (specify):

Nursing Dx. Deficient Fluid Volume

Excessive Fluid Volume

Others : ____________________________________________________________________________

Sleep and Average sleep duration: Average sleep duration:

Rest Pattern
Sleep quality: Sleep quality:

Sleep well Frequently awakened (__x) Sleep well Frequently awakened (__x)
Sleeping position : _____ º ______ pillows
Sleeping position : _____º ______ pillows
Supine Semi Fowler’s High Fowler’s
Supine Semi Fowler’s High Fowler’s
Others (specify)____________
Others (specify)____________

Nursing Dx. Disturbed Sleep Pattern

Others : ____________________________________________________________________________

Elimination Pattern

 Bowel Amount : Amount :

Frequency : Frequency :

Consistency : Consistency :

Others (specify): Others (specify):

Nursing Dx. Constipation

Diarrhea
 Bowel Incontinence

Others : ____________________________________________________________________________

 Urination Amount : 2x3/hari Frequency : Amount : Frequency :

Color : Odor : Color : Odor :

Nocturia Bladder Distention Nocturia Bladder Distention

Nursing Dx. Urinary Incontinence

Others : ____________________________________________________________________________

Activities of Fulfilled independently Fulfilled independently

Daily Livings
Fulfilled with assistance Fulfilled with assistance

Nursing Dx. Activity Intolerance

Others : ____________________________________________________________________________

Hobbies and Type : Type :

Recreation
_____________x/week _____________x/week

Nursing Dx. Activity Intolerance

Others : ____________________________________________________________________________

B. Physical Examination
1. Vital Signs
T: 36,6ºC P : 96 x/menix/m R : 24 x/menit x/m
BP: 150/90 mmHg , MAP:
Weight______Kg
Height______Cm
BMI 20,7 kg/m2_ : _(Normoweight)

Nursing Diagnoses:
Hypothermia
Hyperthermia

2. Glasgow Coma Scale and Level of Consciousness

 PARAMET FINDING SCOR
ER E

Eye opening Spontaneously 4

To speech 3
To pain 2
Do not open 1

Best verbal Oriented 5

response
Confused 4
Inappropriate speech 3
Incomprehensible sounds 2
No verbalization 1

Best motor Obeys command 6

response
Localizes pain 5
Withdraws from pain 4
Abnormal flexion 3
Abnormal extension 2
No motor response 1

Interpretation: Best score = 15; deep coma = 3; 7 or less generally

indicates coma; changes from baseline are most important.

 Level of Consciousness :
Compos Mentis Apathy Somnolence Stuppor Coma
Nursing Diagnoses:
Deficient Fluid Volume
Imbalanced Nutrition: More than body requirements
Skin Integrity, Impaired
Ineffective Airway Clearance
Self-care Deficits
Risk of Aspiration
Communication, Impaired Verbal
______________________________________________________________________
3. Head and neck
a. Head mesocephal nodulelesions scar hematoma bruits sound
normal sinuses tenderness pain facies leonine deformities
&
pale _______________ _________________ ________________
face
 Trigeminal (V) nerve function positive negative
 Hair scaly dry oily fall bald ____________________
 Temporal artery weak strong regular irregular absent

b. Eye conjunctiva anemis exophtalmos enophtalmos ptosis glaucoma

 sunken eyeball icterus strabismus ulcer deviation conjugee
nystagmus cataract retinopathy papilledema emmetropia
myopia hyperopia presbyopia astigmatism photophobia
foreign body eyeglasses contact lens excessive tearing
inflammation hemorrhage exudates edema entropion
ectropion lagophtalmos redness aphakia swelling ____________

 Pupil P E R R L A mydriasis constricted isochors

 Abduscence (VI) nerve function positive negative

c. Ear symmetrical lesions thickening exudates odor pain redness

tenderness deformities __________________ ___________________
d. Nose symmetric deformities lesions exudates obstruction pink moist
red inflammation purpuration ____________ __________________

 Olfactory (I) nerve function positive negative

e. Mouth caries dentures indurations scaly ulcer nodules cracks moist

pink cyanosis redness inflammation _________ ____________
 No. of teeth:____________
 Hypoglossal (XII) nerve function positive negative
 Glossopharyngeal (IX) + Vagus (X) nerve function positive negative
 Facial (VII) + glossopharyngeal (IX) nerve functionpositive negative
f. Throat and neck
symmetrical swelling masses pain on movement bruits sound
Jugular vein(s) distention pain on swallowing ____________________
 Shoulder resistance weak strong
 Lymph nodes small soft tender movable enlarged
 Trachea midline symmetrical deformities deviation
 Carotid artery weak strong regular irregular absent

Nursing Diagnoses:
Deficient Fluid Volume
Infection, Risk for
Imbalanced Nutrition: More than body requirements
Hyperthermia
Swallowing, Impaired
Oral Mucous Membrane, Impaired
Skin Integrity, Impaired
Acute/Chronic Pain
Ineffective Airway Clearance
______________________________________________________________________

4. Chest
a. Inspection accessory respiratory muscle use lesions symmetrical thorax
redness scar dry skin warm squama swelling
gynecomastia retraction Barrel chest _________ ________
  Breast symmetrical smooth extreme vascularity retraction
bulging discharge bleeding scaly indurations masses
______________
b. Palpation
 Apical pulse weak strong regular irregular absent
 Tactile fremitus normal increased decreased
c. Percussion resonance hyper-resonance dullness tympani
 Diaphragmatic excursion 3-5 cm < 3 cm >5 cm *(______cm)
d. Auscultation bronchovesicular vesicular bronchial tubular/tracheal
crackles wheezing _________________ _______________

Nursing Diagnoses:
Skin Integrity, Impaired
Activity Intolerance
Cardiac Output, Decreased
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
Self-care Deficit
Tissue Perfusion, Altered
Acute/Chronic Pain
______________________________________________________________________

5. Upper Extremities
a. Inspection anemia jaundice hyper-pigmented vitiligo striae cyanosis
clubbing finger onycholysis ulcer sikatriks nevi deformities
spider nevi hirsutism ecchymosed paronychia ____________
b. Palpation warm tenderness poor skin turgor ____________ ___________
 Brachial pulses weak strong regular irregular absent
 Radial pulses weak strong regular irregular absent
 Ulnar pulses weak strong regular irregular absent
 Capillary refill normal slow

Senses Left Right

Light/Deep Touch positive negative positive negative

Sharp/dull positive negative positive negative

Warm/cold positive negative positive negative

Vibrations positive negative positive negative

 c. Percussion :

Senses Left Right

Biceps tendon reflex normal hypo hyper normal hypo hyper

normal hypo hyper normal hypo hyper

Triceps tendon reflex

normal hypo hyper normal hypo hyper

Nursing Diagnoses: Brachioradial reflex

Acute/Chronic Pain
Skin Integrity, Impaired
Tissue Perfusion, Altered
Disturbed Body Image
Coping, Ineffective
Infection, Risk for

_____________________________________________________________________

6. Abdomen
a. Inspection symmetrical bulges flat rounded ascites deformities

incision __________ ___________

 Umbilicus midlined inverted

b. Auscultation
 Bowel sounds

o RLQ hyper hypo absent normal

o LLQ hyper hypo absent normal

o LUQ hyper hypo absent normal

o RUQ hyper hypo absent normal

 Bruits sound aorta renal arteries iliac no bruits sound

c. Percussion
o RLQ resonance hyper-resonance dullness tympani

o LLQ resonance hyper-resonance dullness tympani

o LUQ resonance hyper-resonance dullness tympani

o RUQ resonance hyper-resonance dullness tympani

d. Palpation tenderness unusual lump ____________ _______________

 Abdominal superficial reflexes positive negative

Nursing Diagnoses:
Acute/Chronic Pain
Activity Intolerance
Constipation
Diarrhea
_____________________________________________________________________
7. Lower Extremities
a. Inspection anemia jaundice hyper-pigmented vitiligo cyanosis striae
excoriations Ulcer sikatriks nevi spider nevi hirsutism
ecchymosed alopecia ___________ ____________________
b. Palpation papule vesicle pustule squama crust nodule tumor
fissure sub-cutis emphysema dry skin moist warm
tenderness poor skin turgor _________________ _______________
Edema pitting grade: 0 (no pitting) +1(mild pitting)
+2 (moderate pitting) +3 (deep pitting) +4 (severe pitting)
 Femoral Pulses weak strong regular irregular absent
Senses Left Right
Light/Deep Touch positive negative positive negative

Sharp/dull positive negative positive negative

Warm/cold positive negative positive negative

Vibrations positive negative positive negative

 Popliteal pulses weak strong regular irregular absent

 Posterior Tibia pulses weak strong regular irregular absent
 Dorsalis Pedis pulses weak strong regular irregular absent
c. Percussion

Senses Left Right

Quadriceps reflexAchilles normal hypo hyper normal hypo hyper
tendon reflex
normal hypo hyper normal hypo hyper
Babinski sign
normal abnormal normal abnormal
Nursing
Diagnoses:
Mobility, Impaired Physical
Activity Intolerance
Skin Integrity, Impaired
Acute or Chronic Pain
Infection, Risk for
Self-care Deficit
Tissue Perfusion, Altered
______________________________________________________________________
 8. Genitalia
-Male bulges tenderness hernia scar secretion tumor
varicocele hydrocele inflammation odorous nodule
swelling redness dirty ___________ _______________
-Female inflammation ulcer secretion swelling nodule
cystocele rectocele bulges odorous tenderness
scar redness dirty ____________ _____________ _________

Nursing Diagnoses:
Infection, Risk for
Acute or Chronic Pain
Skin Integrity, Impaired
_________________________________________________________________________________
C. Social Data
 Social status single married widow divorced
 Social activities organization(s) :_________________________________________________
not involved
Nursing Diagnoses:
Social Interaction, Impaired
Social Isolation
Loneliness, Risk for
Coping, Ineffective
_________________________________________________________________________________
D. Spiritual Data
 Worship attendance always often sometimes rare never
 Needs priests/friends to pray yes no
Nursing Diagnoses:
Spiritual Distress
Hopelessness
____________________________________________________________________________
E. Psychological Data
 Expression sad frowning smiling comfort appearance _________
 Emotion anxious afraid angry irritability relax _____________
 Coping strategy independent need assistance
Nursing Diagnoses:
Anxiety
Hopelessness
Coping, Ineffective
_________________________________________________________________________________

VII. Diagnostic Tests

No. Kinds of Test Normal Values Patients’ result Interpretation

 Reference(s):

- Peningkatan JVP Jantung

- Gallop S3

- Nadi diskenetik

- Sinosis perifer

- Nadi mengecil ketika

berat

Dominan Asites Hepar

- JVP normal atau rendah

- Ikterik

- Eritema Palma

r - Spider Angiomata

- Gynecomastia pada
lakilaki

- Asterixis

- Hipetensi Ginjal (Gagal Ginjal

Kronik)
- Hipertensif retinopati

- Uremic fetor

- Edema Periorbita Ginjal (Sindrom

Nefrotik)
- Hiperensi

Other Tests
 VIII. Medication and Treatment

No. Drug’s Name Classification Dose Contents *Indications *Contraindications *Adverse Reactions *Nursing Implications

3
4

*Indication, contraindication, adverse reactions and nursing implications must be at least one reference
IX. Data Analysis

“S” and “O” data Etiology Problem

1stDay
 2rdday

X. Nursing Diagnosis According to Priority

First Day
1.
2.
3.
4.
5.
Second Day
1.
2.
3.
4.

5
 Form NCP (Nursing Care Plans)
Pt. Name: Age: Room/Bed: Medical Diagnosis: Physician’s Name:

Date/ Planning
No. Nursing Diagnosis* Implementation Evaluation
Time Goal* Interventions* Rationale*

*must be with reference(s)

 JOURNAL

Nama Klien:
Room:
Diagnosa:
References: