WOC RENAL TRANSPLANTATION

Vascular UTI, Urolithiasis, Renal tumors

disease Glomerulone BPH
phritis, ARF

Ecocardium,
contractility
Obstruction
disorders
of urinary
system
CO ↓

Reduce blood flow to kidney

Systemic hipertention in the

glomerulus

Failure of nephrone function

GFR

CHRONIC RENAL FAILURE

INDICATION RENAL TRANSPLATATION

PRE OP POST OP

Patient affraid Rejection Wound Port de entry

to have incisions
Retention of
operatio
Na+ and H20 Decrease
rena flow Damage to HIGH RISK
Patient cell and INFECTION
anxiety All of urine tissue
↑ Hydrostatic cannot get
pressure ANXIETY out
Stimulation
of pain
sensory
 Move fluid Disfunction Little urine Release
from renal to chemical
intravascular excretion mediator
to interstitial Oliguria,
anuria
BUN & Release
edema Creatinin bradikinin
Impairment
of urine
Shine skin Uremia elimination
Hyptothalam
us
EXCESS Retention of
SKin
FLUID Na+ and H20
VOLUME
Cortex
Accumulate
cerebry
of urea ↑ Hydrostatic
crystals in pressure
skin
Nosiceptor
pruritus Move fluid
from
intravascular
lession to interstitial
Intepretation
of pain
IMPAIRED edema
SKIN
INTEGRIT
EXCESS Pain at pelvic
Y
FLUID
VOLUME

ACUTE
PAIN
 BAB 3

NURSING CARE

PRE OP

3.1. Nursing assesment

1. Age :
Can attack all ages
2. Chief complain :
Patient complain that edema
3. Health history now :
Other complaints : Glomerulonephritis, Pylonephritis, NTA, UTI (Urinary
Tract Infection).
4. Health history before :
Acute Renal Failure (ARF)
5. Physical examination :
 B1 : -
 B2 : -
 B3 : -
 B4 : Oliguria, anuria.
 B5 : Increase weight gain abnormally
 B6 : lession, pruritus, shine skin, edema, red skin, itchy skin, peeling skin
3.2. Data Analysis
Data Etiology Problem
Subjective Data : Chronic Renal Excess Fluid Volume

- Patient complaint of
Disfunction renal to
the body swollen excretion the waste

Objective Data : Disfunction to excretion
- Edema Na+

- Increase weight gain Retention of Na+ and
abnormal H2O

- Shine Skin Hydrostatic pressure
- Oliguria 
Fluid from intravas to
- Anuria extrasel

Edema
 
Shine skin

Excess Fluid Volume
Subjective Data : Chronic Renal Impaired skin integrity

- Patient complaint
Disfunction renal to
itchy skin excretion the waste

Objective Data : BUN & Creatinin
- Lesion 
Uremia
- Pruritus 
- Shine Skin Skin

- Edema Accumulate of urea
- Redness (red skin) crystals in the skin

Peeling Skin Pruritus

Lession

Impaired skin integrity

Subjective data : Chronic renal Anxiety

↓
Patient said affraid to
Patient affraid to have an
have an operation operation
↓
Objective data :
Patient anxiety
Patient affraid ↓
Anxiety
Patient anxiety

3.3. Nursing diagnosis

1. Excess Fluid Volume R/T decrease Glomerular Filtration Rate and sodium
retention is characterized by Patient complaint of the body swollen, edema,
increase weight gain abnormal, shine skin, oliguria, anuria.
2. Impaired skin integrity R/T skin wounds is characterized by Patient complaint
itchy skin, lesion, pruritus, shine skin, edema, redness, peeling skin
3. Anxiety R/T Procedure operation characterized by Patient said affraid to have
an operation, patient anxiety, patient affraid.
 3.4. Intervention
Nursing diagnose Objective and Expected Intervention Rationale
Outcomes
Excess Fluid After act of nursing for 5x24 Explained about the By explaining to the
Volume R/T hour, expected excess fluid patient’s condition patient, the patient
decrease volume can be resolved, with out and the actions to do will know about his
Glomerular comes: condition and will
Filtration Rate and A. Patient coperative cooperative to
sodium retention is B. Patient doesn’t complaint of follow action
characterized by the body swollen
Patient complaint C. Decrease edema Set position lift up the With set position lift
of the body D. Weight gain normal/ increase leg up the leg can
swollen, edema, E. Increasing urine released increase venous
increase weight return
gain abnormal,
shine skin, oliguria,
anuria Collaboration with With to give diuretic
physician to give expected in the
diuretic intracellular fliud
back into the
extracellular

Collaboration with Feeding high in

nutritionists to give natrium can cause
low natrium diet accumulate fluid

Monitoring urine With monitoring

output urine output
expected to know the
amount of urine that
comes out in a day
Impaired skin After act of nursing for 5x24 Explained about the By explaining to the
integrity R/T skin hour, Impaired skin integrity can patient’s condition patient, the patient
wounds is be resolved, with out comes: and the actions to do will know about his
characterized by A.Patient cooperative condition and will
Patient complaint B.Patient doesn’t complaint cooperative to
itchy skin, lesion, itchy skin follow action
pruritus, shine skin, C. No pruritus
edema, redness, D.No lesion, redness, peeling Keep dry and wrinkle- Lowering the dermal
peeling skin. skin free linens irritation and the risk
E.No edema of skin damage

Collaborated with Ointment or cream

physician to give may be desirable to
ointments or creams reduce pruritus
for pruritus

Monitor skin to lesion, Indicates poor

redness, peeling skin circulation area /
damage that can lead
to the establishment
of infection

Inspection of the area edema tends to

depends on edema damage the skin
tissue
Anxiety R/T After act of nursing for 5x24 explain to the family By explaining to
Procedure hour, Impaired skin integrity can or the patient's parents family or the
operation be resolved, with out comes : about the patient’s patient's parents will
characterized by 1. Patient dont affraid to condition and the know about his
Patient said affraid have an operation actions to do condition and will
to have an 2. Patient dont have anxiety cooperative to
operation, patient again follow action
anxiety, patient
affraid.
Tell the patient about Decrease the patient
the room and anxiety.
procedure, on
operation room

provide support to family provides a

families to settle in the sense of security and
room with the patient comfort
POST OP

3.5. Nursing assesment

1. Age :
Can attack all ages
2. Chief complain :
Patient complain pain in wound incicions
3. Health history now :
Pain in wound incicions, oliguria
4. Health history before :
Chronic Renal Failure (CRF)
5. Physical examination :
A. B1 : tachipnea
B. B2 : tachycardi
C. B3 :
1) P : Wound incisions
2) Q : Pain is like as burn
3) R : Pain at the pelvic
4) S : Pain scale 6
5) T : Intermitten
D. B4 : Oliguria, anuria, edema
E. B5 : -
F. B6 : wound incisions, shine skin
3.6. Data analysis
No. Data Etiology Nursing problem
1. DS : patients complaint pain Acute pain
in wound incisions
DO :
1) P : Wound incisions
2) Q : Pain is like as burn
3) R : Pain at the pelvic
4) S : Pain scale 6
5) T : Intermitten
6) Tachycardi
 7) Tachipnea
2. DS : patients complaint a Impairment of
little urinate urine elimination
DO :
1. oliguria
2. anuria
3. DS : patients complaint the Excess fluid
body swollen volume
DO :
1. shine skin
2. edema
4. DS : - High risk
DO : wound incisions infection

3.7. Nursing diagnose

1. Acute pain R/T tissues trauma effect transplant renal is characterized by
patients complaint pain in wound incisions, P : Wound incisions, Q : Pain is
like as burn, R : Pain at the pelvic , S : Pain scale 6, T : Intermitten,
Tachycardi, tachipnea.
2. Impairment of urine elimination R/T decreasing glomerular filtrate effect
rejection transplant renal is characterized by patients complaint a little urinate,
oliguria, anuria.
3. High risk infection R/T exposed microorganism
3.8. Intervention

Nursing diagnose Objective and Intervention Rationale

Expected Outcomes
Acute pain R/T After act of nursing 1. Explain about the 1. By explaining to
tissues trauma effect for 2x24 hour, acute patient’s condition the patient, the
transplant renal is pain can be resolved, and the actions to patient will know
characterized by with out comes: do about his
patients complaint condition and will
pain in wound cooperative to
incisions, P : Wound follow nursing
incisions, Q : Pain is action
like as burn, R : Pain 2. Teach and 2. distraction and
at the pelvic , S : motivation the relaxation can
Pain scale 6, T : patients to do decrease the pain
Intermitten, distraction and
Tachycardi, relaxation
tachipnea. techniques
3. give the 3. With the
comfortable comfortable
position position can
relieve the pain
4. Collaboration with 4. Analgesic can an
physician about block the CNS to
analgesic drug the smoothly
therapy circulation blood
5. Record the 5. Provide in
location, duration / formation to assist
intensity of pain in determining the
(scale 1-10) choice of
intervention
6. Monitor vital sign 6. Monitor vital sign,
(HR, RR) we can know the
condition of the
patient and to plan
the next nursing
action
Impairment of urine After act of nursing 1. Explain about the 1. By explaining to
elimination R/T for 4x24 hour, patient’s condition the patient, the
decreasing Impairment of urine and the actions to patient will know
glomerular filtrate elimination can be do about his
effect rejection resolved, with out condition and will
transplant renal is comes:
cooperative to
characterized by
follow action
patients complaint a 2. Determine the 2. With determine
little urinate, quantity of fluid the quantity of
oliguria, anuria. which enter fluid which enter
can help when
measuring urine
output
3. Palpate the 3. With palpatte the
bladder bladder expected
to know
accumulation fluid
in bladder
4. Collaboration for 4. With collaboration
laboratory test for laboratory test
expected can help
knowing the
content of the
urine
5. With collaboration
5. Collaboration with for renal
physcians about transplantation
renal can increase renal
transpantation function
6. With monitor
intake and output
6. Monitor intake expected to help
and output measuring fluid
balance
High risk infection After act of nursing 1. Explain to clients 1. Clients know
R/T exposed for 4x24 hour, high about the disease about the
microorganism risk infection don’t and the measures disease that he
happen, with out to be taken suffered and
comes: cooperative
with the
actions that
will be given
2. Use aseptic 2. Prevent the
technique for introduction
wound care of bacteria at
the incision
area
3. Collaboration 3. Antibiotics
with physicians can prevent
antibiotics and kill the
bacteria
4. Observation for 4. With the
signs of infection color, dolor,
(color, dolor, rubor, tumor,
rubor, tumor, fungsiolaesa
fungsiolaesa) indicate an
infection