PENDEKATAN PROSES KEPERAWATAN PADA PASIEN PENYAKIT GINJAL KRONIK STADIUM V YANG MENJALANI HEMODIALISIS DENGAN NYERI AKUT DAN PERFUSI PERIFER TIDAK EFEKTIF: STUDI KASUS

Abstract

ABSTRACT

Patients with stage V chronic kidney disease (CKD) undergoing hemodialysis experience complex clinical problems, including pain, hemodynamic disturbances, anemia, impaired peripheral perfusion, and fluid imbalance. However, documentation integrating these findings into the assessment and nursing care planning process in individual cases remains limited. This study is important because it provides a systematic description of clinical assessment and nursing decision-making for hemodialysis patients with complex clinical conditions. This study aimed to describe the assessment findings, nursing diagnoses, expected outcomes, and planned nursing interventions in a patient with stage V CKD undergoing hemodialysis who experienced acute pain and ineffective peripheral tissue perfusion. A descriptive case study design was used. Data were collected through interviews, observation, physical examination, vital sign and pain assessment, peripheral perfusion assessment, laboratory results, medical records, and hemodialysis documentation. Data were analyzed by integrating subjective and objective findings based on the Indonesian Nursing Diagnosis, Outcome, and Intervention Standards (SDKI, SLKI, and SIKI). The findings showed occipital headache with a pain intensity of 4/10, blood pressure of 178/88 mmHg, cold extremities, capillary refill time >2 seconds, hemoglobin of 7.1 g/dL, and urine output of 200–300 mL/day. The priority nursing diagnoses were acute pain and ineffective peripheral tissue perfusion. In conclusion, comprehensive assessment supported individualized nursing priorities and care planning. However, intervention effectiveness could not be objectively evaluated because implementation and serial evaluation data were unavailable.

ABSTRAK

Pasien penyakit ginjal kronik (PGK) stadium V yang menjalani hemodialisis menghadapi masalah klinis kompleks, termasuk nyeri, gangguan hemodinamik, anemia, perubahan perfusi perifer, dan ketidakseimbangan cairan. Namun, dokumentasi yang mengintegrasikan temuan tersebut ke dalam proses pengkajian dan perencanaan asuhan keperawatan pada kasus individual masih terbatas. Penelitian ini penting untuk memberikan gambaran sistematis mengenai pengambilan keputusan keperawatan berbasis kondisi klinis pasien hemodialisis. Penelitian ini bertujuan menggambarkan hasil pengkajian, penetapan diagnosis, luaran, dan perencanaan intervensi keperawatan pada pasien PGK stadium V yang menjalani hemodialisis dengan nyeri akut dan perfusi perifer tidak efektif. Penelitian menggunakan desain studi kasus deskriptif. Data diperoleh melalui wawancara, observasi, pemeriksaan fisik, pengukuran tanda vital dan nyeri, pemeriksaan perfusi perifer, telaah laboratorium, serta rekam medis dan catatan hemodialisis. Analisis dilakukan dengan mengintegrasikan data subjektif dan objektif berdasarkan SDKI, SLKI, dan SIKI. Hasil menunjukkan nyeri kepala oksipital skala 4/10, tekanan darah 178/88 mmHg, akral dingin, CRT >2 detik, hemoglobin 7,1 g/dL, serta produksi urine 200–300 mL/hari. Diagnosis prioritas adalah nyeri akut dan perfusi perifer tidak efektif. Kesimpulannya, pengkajian komprehensif mendukung penetapan prioritas dan perencanaan asuhan yang individual. Efektivitas intervensi belum dapat dinilai secara objektif karena implementasi dan evaluasi serial tidak tersedia.