THE OUTLINE OF WRITING TASK

ENGLISH LANGUAGE

Supporting Lecturer :
Ns. Eka Malfasari, M.Kep, Sp.Kep.J

Class 1A
8 Group :

Diah Fitri Wardani

Karunia Fitri
Nadya Farhana Putri
Salwa Andini Chelsea
Yulinnisa Indan

NURSING FACULTY
PEKANBARU STATE UMBRELLA HEALTH INSTITUTE
YEAR 2024
CASE 8
A woman 73 year old woman was admitted on the 3rd day to the internal
medicine unit with complaints of swelling in both legs. The patient was admitted
to the ER by his family with complaints of swelling in both legs. The patient
complained of swelling since 5 days of SMRS. Swelling was initially felt to
appear first in the left leg and was followed by swelling in the right leg, the
swelling was felt to be getting bigger and shinier day by day, the leg was said to
not feel painful and not feel hot. The patient also complained of pain in both knees
since 2 weeks of SMRS, making it difficult for the patient to walk. The knees also
feel a bit stiff, knee pain is felt more during activities. The patient has no fever,
cough or shortness of breath. The patient said his body felt weak since 3 SMRS.
The pain is felt throughout the body, making the patient reluctant to carry out
activities. BAK 4-5 times a day with an amount of ¼ to ½ glass per day. Patients
can drink 2 bottles of medium mineral water (@600 mL) a day. Defecation is
normal and there are no disorders.
When the assessment was carried out, the patient still complained of
swelling in his legs and pain in both knees which made it difficult for him to carry
out activities. The patient also still feels tired and has no energy. Weakness is felt
continuously and does not improve with rest. The patient has a history of
uncontrolled hypertension since 10 years ago. The patient takes amlodipine once a
day but not regularly. There is no history of kidney disease, nor are there any
allergies. The family has a history of heart disease and hypertension, cancer (-),
DM (-), and lung disease (-). The patient is a retired civil servant, and in his daily
life he stays at home, cooks and looks after his grandchildren. The patient has no
history of smoking or drinking alcohol.
The results of the physical examination showed a general condition of
moderate pain, CM consciousness, blood pressure 150/90 mmHg, pulse frequency
84 times/minute, respiratory frequency 20 times/minute, and temperature 36.20C.
the pain scale felt by the patient is 3 (0-10). Anemic conjunctiva, sclera not icteric,
pupil reflex +/+, no lymph node enlargement, JVP 5+1 cm H2O. the mucous
membrane of the lips is not cyanotic, not dry, the chest wall movement is
symmetrical, the ictus cordis is not visible or palpable. There is no chest wall
retraction, right/left vesicular breath sounds, crackles (-), heart sounds S1
followed by S2 single and regular without murmur. Vocal fremitus is the same on
the right and left. The abdomen is not distended, there are no scars, bowel sounds
10 times/minute, the liver is not palpable, the spleen is not palpable, there is no
suprapubic tenderness. Extremities feel warm, edema +2 in both legs, skin looks
shiny, CRT 3 seconds. Complete blood test results WBC 12000/µL; RBC 2.49
million/μL; HB 6.78 g/dl; HCT 21.81%; MCV 87.46fL; MCH27.17 Pg; MCHC
31.07 g/dl; RDW 12.6%; PLT 354200/uL. Blood chemistry examination SGOT
20.3 U/L; SGPT 19.1 U/L; albumin 3.2 g/dl; GDS 89 mg/dl; BUN 90.4 mg/dl;
creatinine 6.39 mg/dl; uric acid 8.7 mg/dl; potassium 4.51 mmol/L; sodium 140
mmol/L. AGD results pH 7.27; pCO2 23.3 mmHg; pO2 96.7 mmol/L; HCO3 10.5
mmol/L, BE -16.3 SaO2 96.7%. Examination of ferritin iron status 244.80 g/dl,
serum iron 40.46 U/L; TIBC 164 U/L. The results of the chest x-ray showed
aortosclerosis and pulmonary abnormalities, thoracic spondylosis. An ultrasound
photo of the upper and lower abdomen showed CKD stage V. X-rays of the genu
dextra and left AP/lateral showed osteoarthritis with CPPD.
The patient received IVFD therapy with 0.9% NaCl 8 drops per minute,
CKD diet 35 kcal/kgBW/day + 0.8 g protein/kgBW/day, allopurinol 100 mg/24
hours, paracetamol 500-750 mg/8 hours orally, pro hemodialysis, PRC 2 kolf on
HD transfusion, captopril 12.5 mg/8 hours, bisoprolol 1.25 mg/24 hours.
Nursing Diagnoses: hypervolemia related to impaired regulatory mechanisms
Nursing Intervention: Management of hypervolemia

1. Nursing Assesment
Results of the identity history of patients with CKD Stage V

Anamnesis data Patient

Patient’s name Mrs. Z
Age 73 years old
Gender Woman
Reason for admission or t The patient was admitted to the ER by his family
he main complaint with complaints of swelling in both legs. The patie
nt complained of swelling since 5 days of SMRS.
 Swelling was initially felt to appear first on the left
leg and was followed by swelling on the right leg,
the swelling was felt to be getting bigger and shini
er day by day, the leg was said to not feel painful a
nd not feel hot. The patient also complained of pai
n in both knees since 2 weeks of SMRS, making it
difficult for the patient to walk. The knees also feel
a bit stiff, knee pain is felt more during activities.
The patient has no fever, cough or shortness of bre
ath. The patient said his body felt weak since 3 SM
RS. The pain is felt throughout the body, making t
he patient reluctant to carry out activities. BAK 4-
5 times a day with an amount of ¼ to ½ glass per d
ay. Patients can drink 2 bottles of medium mineral
water (@600 mL) a day. Defecation is normal and
there are no disorders.
Past medical history - The patient has a history of uncontrolled hyper
tension since 10 years ago.
- The patient takes amlodipine once a day but no
t regularly. There is no history of kidney diseas
e, nor are there any allergies.
- The family has a history of heart disease and h
ypertension, cancer (-), DM (-), and lung disea
se (-).
- The patient is a retired civil servant, and in his
daily life he stays at home, cooks and looks aft
er his grandchildren.
- The patient has no history of smoking or drinki
ng alcohol.
Past surgical history No past Surgical History
Allergies history No history of allergies
Physical assessment (Sign - General condition of moderate illness
s and symptoms) fromhea - CM consciousness
d to toe or per system - Blood pressure 150/90 mmHg
- Pulse frequency 84 times/minute,
- Respiratory frequency 20 times/minute
- Temperature 36.20C
- Pain scale felt by the patient 3 (0-10)
Eyes : Anemic conjunctiva, sclera not icteric,
pupillary reflex +/+
 Neck : no KGB enlargement, JVP 5+1 cm H2O
Chest : Symmetrical chest wall movement, ictus
cordis is not visible or palpable. There is no chest
wall retraction, right/left vesicular breath sounds,
rhonchi (-)
Cardiovascular : S1 heart sound followed by S2
single and regular without murmur. Vocal fremitus
is the same on the right and left.
Abdomen : The abdomen is not distended, there
are no scars, bowel sounds 10 times/minute, the
liver is not palpable, the spleen is not palpable,
there is no suprapubic tenderness.
Extremity : teraba hangat, edema +2 pada kedua
tungkai, kulit tampak mengkilat, CRT 3 detik.
Psychosocial assesment There is swelling in the legs and pain in both knees
which makes it difficult to carry out activities. The
patient also still feels tired and has no energy.
Laboratory assesment - Complete blood test results WBC 12000/µL
- RBC 2.49 million/Μl
- HB 6.78 g/dl; HCT 21.81%
- MCV 87.46fL
- MCH27.17 Pg
- MCHC 31.07 g/dl
- RDW 12.6%
- PLT 354200/uL
- Blood chemistry examination SGOT 20.3 U/L
- SGPT 19.1 U/L
- Albumin 3.2 g/dl, GDS 89 mg/dl, BUN 90.4
mg/dl, creatinine 6.39 mg/dl, uric acid 8.7
mg/dl, potassium 4.51 mmol/L, sodium 140
mmol/L.
- AGD results pH 7.27, pCO2 23.3 mmHg, pO2
96.7 mmol/L, HCO3 10.5 mmol/L, BE -16.3
- SaO2 96.7%.
- Examination of ferritin iron status 244.80 g/dl,
serum iron 40.46 U/L; TIBC 164 U/L.
Imaging assesment No Imaging Assessment
Other diagnostic assesmen The results of the chest x-ray showed
t aortosclerosis and pulmonary abnormalities,
thoracic spondylosis. An ultrasound photo of the
 upper and lower abdomen showed CKD stage V.
X-rays of the genu dextra and left AP/lateral
showed osteoarthritis with CPPD.

2. Analysis (Nursing Diagnosis)

Hypervolemia related to impaired regulatory mechanisms
NO. DATA FOCUS ETIOLOGI PROBLEM
1. 1. Subjective data: Disorders of kidne
- Complained that there was st y function and str Hypervolemia
ill swelling in his legs and pa ucture
in in both knees which made
it difficult for him to carry ou
t activities inability of the
- The patient also complained kidneys to excrete
of pain in both knees since 2 urine
weeks of SMRS, making it di
fficult for the patient to walk.
The knees also feel a bit stif Fluid, Na and
f, knee pain is felt more durin electrolyte
g activities retention
- The patient said his body felt
weak since 3 SMRS. The pai
n is felt throughout the body, increased body
making the patient reluctant t fluids, edema
o carry out activities.

2. Objective data :
- General condition of m
oderate illness
- CM consciousness
- Blood pressure 150/90
mmHg
- Pulse frequency 84 tim
es/minute,
- Respiratory frequency
20 times/minute
- Temperature 36.20C
- Pain scale felt by the p
atient 3 (0-10)
 3. Nursing Planning (Intervention)
Nursing diag Nursing Outcomes Nursing interventions
noses
Hypervolemi After carrying out nursing Nursing Interventions
a Related To I Management of Hypervolemia
actions 1 x 24 hours, it is
mpaired Regu
latory Mecha hoped that the fluid Observations:
nisms - Check for signs and symptoms
balance will improve with
of hypervolemia
the following criteria: - Identify the cause of
hypervolemia
- Increased fluid intake
- Monitor hemodynamic status
- Urine output increases
Therapeutic :
- Edema decreases
- Weigh yourself every day at
- Blood pressure improves the same time
- Limit fluid and salt intake
- Skin turgor improves
- Elevate the head of the bed 30-
40 degrees

Education :
- Advise to report if urine output
<0.5mL/kg/hour within 6
hours
- Advise to report if body
weight increases >1 kg in a
day
- Teach how to measure and
record fluid intake and output

Collaboration :
- Collaboration with diuretic
administration
- Collaborative replacement of
potassium loss due to diuretics
4. Nursing Implementation
NO. Execution Nursing Diagnoses Implementation
Time
1. 24 Juni, at Hypervolemia Relate 1. Observe vital signs
9:00 am d To Impaired Regul 2. Observe fluid intake and
atory Mechanisms output
3. Monitor your weight every day
 4. Give diuretic medication
5. Set a comfortable position

5. Evaluation
NO. Implementatio Nursing Diag Evaluation (SOAP)
n Time nosis
1. 24 Juni, at 9:00 Hypervolemia S : The patient said his legs were not
am Related To Im as swollen as before, he could do
paired Regula activities slowly
tory Mechani
sms O : general condition of moderate pa
in, CM consciousness, blood pressur
e 150/90 mmHg, pulse frequency 84
times/minute, respiratory frequency
20 times/minute, and temperature 36.
20C. the pain scale felt by the patient
is 3 (0-10).

A : Hypervolemia

P : intervention continues