Analisis Asuhan Keperawatan pada Pasien dengan Gagal Ginjal Kronik di ICU RSUP Dr. Sardjito dengan Pendekatan NANDA NOC NIC: Studi Kasus

Abstract

Background: Dialysis is a method of maintaining body function in patients with Chronic Kidney Disease (CKD). Dialysis therapy causes several complications. Therefore, it needs special approach to ensure that the nursing process of CKD patients who undergoing hemodialysis goes well.
Objective: To analyze a CKD case using North American Nursing Diagnosis Association-Nursing Outcome Classification-Nursing Intervention Classification (NANDA-NOC-NIC) approach.
Case report: Due to dialysate inability to draw fluids, patient’s main complaint was whole-body swelling and short of breath feeling after light activity. The patient had acute breath shortness with a respiratory rate of 34 times per minute and an oxygen saturation of 80%. CPR was provided to the patient for 30 minutes, and OPA was installed. As a result of the activity, the patient's oxygen saturation rose between 85 to 90% and developed ROSC.
Result: The nursing diagnoses indicated that there was excessive fluid volume and exercise intolerance. The NOC NIC criteria were used to guide the intervention, which comprised fluid management, fluid monitoring, and exercise therapy.
Conclusion: There are two nursing problems in this study case, based on NANDA-NOC-NIC approach, ie.: excessive fluid volume and activity intolerance.

ABSTRAK

Latar belakang: Terapi dialisis merupakan cara untuk mempertahankan fungsi tubuh pada kondisi Gagal Ginjal Kronik (GGK). Terapi dialisis juga menyebabkan beberapa komplikasi, sehingga memerlukan pendekatan khusus untuk menangani, agar proses keperawatan pasien GGK yang menjalani hemodialisis berjalan dengan baik.
Tujuan: menganalisis kasus gagal ginjal kronik melalui pendekatan North American Nursing Diagnosis Association-Nursing Outcome Classification-Nursing Intervention Classification (NANDA-NOC-NIC).
Studi kasus: Keluhan utama bengkak seluruh tubuh dan merasa sesak nafas setelah aktivitas ringan akibat dialisat gagal menarik cairan. Pasien mengalami sesak nafas berat, RR 34x/menit, saturasi oksigen 80%. Pasien diberikan RJP selama 30 menit serta pemasangan OPA. Hasil tindakan yakni saturasi oksigen mencapai 85% hingga 90%, kemudian pasien mengalami ROSC.
Hasil: Diagnosis keperawatan yang ditegakkan adalah kelebihan volume cairan dan intoleransi aktivitas. Intervensi yang diberikan pada diagnosis berdasarkan kriteria NOC NIC meliputi manajemen dan monitoring cairan, serta terapi aktivitas.
Simpulan: Ada dua masalah keperawatan dalam studi kasus ini, berdasarkan pendekatan NANDA-NOC-NIC, yaitu kelebihan volume cairan dan intoleransi aktivitas.