J.

Implementation
No. Date/Time Nursing Diagnose Implementation Patient Response Sign
1 August 27th, Volume Excess 1. Monitoring intake and 1. DS: Mr. S is willing to monitor and be
2019 related to output asked about fluid inputs and outputs
9 AM Compromised 2. Monitoring for signs of DO: -Inputs: 1750 cc
regulatory excess fluid (edema, Outputs: 1550 cc
mechanisms crackles, neck vein 2. DS: Mr. S is willing to monitor for
distension) signs of excess fluid
3. Educating hemodialysis DO: there is no clinical sign of excess
fluid
3. DS: Mr. S is willing to do hemodialysis
therapy
DO: Mr. S conducted a hemodialysis
program at 09.00 am
 Ineffective Peripheral 1. Monitoring the presence 1. DS: The client is willing to monitor the
Tissue Perfusion of paretese presence of parets, Mr. S doesn't feel
related to
2. Giving instructions to tingling
the family to notify if DO: -
there is a laceration 2. DS: The family is willing to
3. Monitoring Ability immediately notify if there is a
Capability laceration
4. Monitoring vital sign DO: No visible laceration
3. DS: The family is willing to be
monitored for their defecation
4. DO: CHAPTER 1 time in the morning,
soft, no signs of constipation
5. DS: The client is willing to do a TTV
monitor
DO:
RR= 19 breath
Temperature = 36.2 C
HR= 86 beats
BP= 150/90 mmHg
2 August 27th, Volume Excess Fluid 1. Monitoring intake and 1. DS: Mr. S is willing to monitor and be
2019 related to output asked about fluid inputs and outputs
3 PM Compromised 2. Monitoring for signs of DO: Inputs: 1800 ml
regulatory excess fluid (edema, Outputs: 1500 ml
mechanisms crackles, neck vein 2. DS: Mr. S is willing to monitor for
distension) signs of excess fluid
DO: there is no sign of excess fluid
Ineffective Peripheral 1. Monitoring the presence 1. DS: The client is willing to monitor
Tissue Perfusion of paretese paretese, the client does not complain
related to 2. Monitoring Ability of tingling
Hipertension Capability DO: -
3. Monitoring vital sign 2. DS: The family is willing to be
monitored for their bowel movements
DO: The client has defecated in the
morning, consistency of soft stool, no
constipation.
3. DS: The client is willing to do a TTV
monitor
DO:
RR: 20 breath
Temperature: 35.6 C
HR: 82 beat
BP: 140/90 mmHg
Acute pain related to 1. Educating to increase 1. DS: Mr. S willing to increase rest time
post surgery rest DO: The client says he can sleep 7
2. Teaching hours a day - 8 hours
nonpharmacology 2. DS: Mr. S is willing to do relaxation
techniques techniques if pain occurs
3. Providing analgesic DO: Clients can apply breathing
fentanyl 20 tpm which is techniques on their own
entered with the RL 3. DS: Mr. S is willing to be given
according to medical treatment in the form of IV
collaboration with the fluids in the form of analgesic drugs to
doctor treat pain
4. carry out assessment / DO: Mr. S has received fentanyl + RL
monitoring of pain 20 TPM therapy
4. Mr. S willing to do a pain assessment,
from the data:
P: Pain when wake up from sleep
Q: pain like being stabbed
R: pain in the scrotum area
S: 5
Q: Intermittent
3 August 29th, Volume Excess Fluid 1. Monitoring intake and 1. DS: Mr. S is willing to monitor and be
2019 related to output asked about fluid inputs and outputs
9 AM Compromised 2. Monitoring for signs of DO: Input: 1700
regulatory excess fluid (edema, Output: 1500
mechanisms crackles, neck vein 2. DS: Mr. S is willing to monitor for
distension) signs of excess fluid
DO: there are no clinical signs of fluid
overload
Ineffective Peripheral 1. Monitoring the presence 1. DS: The client is willing to monitor the
Tissue Perfusion of paretese presence of parets, Mr. S doesn't feel
related to 2. Giving instructions to tingling in the peripheral area
Hipertension the family to notify if DO: -
there is a laceration S: The family is willing to immediately
3. Monitoring Ability notify if there is a laceration
Capability DO: There are no signs of laceration
4. Monitoring vital sign 2. DS: The family is willing to be
monitored for their bowel movements
DO: Mr. A CHAPTER this morning
3. DS: The client is willing to do a TTV
monitor
DO:
 RR: 18 breath
Temperature : 36.5 C
HR: 76 beats
BP: 130/90 mmHg
Acute pain related to 1. Giving 20 tpm analgesic 1. DS: Mr. S is willing to be given
post surgery fentanyl that is inserted medical treatment in the form of IV
with the RL in fluids in the form of analgesic drugs to
collaboration with the treat pain
doctor DO: the client is getting fentanyl
2. Performing pain therapy
assessment / monitoring 2. DS: Mr. S willing to do a pain
assessment
P: clients feel pain when going to sit
Q: pain like being stabbed
R: pain in the scrotum area
DO:
The client still grimaces when
instructed to wake up
No. Date / time Nursing Diagnose SOAP Sign
1. Agustus 27th 2019/ Volume Excess S: Mr. S said urinated 3 times a day
2 AM Fluid related to O:
Compromised • Input: 1750 fluids, originating from 1500 cc of
regulatory intravenous fluids and 1 liter of drinking
mechanisms Fluid output comes from 1050cc IWL and the rest
urinates, today's client has also conducted a
hemodialysis program
• There are no signs of excess fluid volume (Edema (-),
Effusion (-))
A: Imbalance output and intake
Q: Continue monitoring intake and output and signs of
excess fluid volume
Ineffective S: Mr. S doesn't feel Paretese
Peripheral Tissue O:
Perfusion related to - the patient said that defecated 1x / day, consistency of
Hipertension soft stool, no constipation
-No laceration
-TTV inspection
TD: 150 mmHg
Temperature: 36.3 C
 RR: 21 x breath
HR: 75 beats
A: There is no sign of ineffective tissue perfusion, but
the client is still hypertensive
P: Continue monitoring, collaborating the
administration of tension-reducing drugs (amlodipine)
2. August 12th, 2019/ Volume Excess S:Mr. S said miksi 3 times a day
10 PM Fluid related to O: Input: liquid 1750, originating from 750 cc of
Compromised intravenous fluids and 1 liter of drinking
regulatory The liquid output of 1500 comes from 1050cc IWL and
mechanisms the rest urinates
• There are no signs of excess fluid volume (Edema (-),
Effusion (-))
A: Imbalance of intake and output
P: Continue monitoring for intake and output as well as
monitoring for clinical manifestations of fluid overload
or not
Ineffective S: Mr. S doesn't feel Paretese
Peripheral Tissue O:
Perfusion related to - ABAB smooth 1x / day, consistency of soft stool, no
Hipertension constipation
 -No laceration
-TTV inspection
TD: 140 mmHg
Temperature: 36.2 C
RR: 20 breath
PR: 70 beats
A: There is no sign of ineffective tissue perfusion, but
the client is still hypertensive
P: Continue monitoring, collaborating the
administration of tension-reducing drugs (amlodipine)
Acute pain related S: Mr. S complained of postoperative pain
Volume Excess P: Pain when wake up from sleep
Fluid related to Q: Pain like being stabbed
Compromised R: Pain in the scrotum area
regulatory S: 3
mechanisms to post Q: Missing Arises after Post Op
surgery O: The patient looks rowdy
A: The patient feels acute pain
P: Continue monitoring pain and continue to provide
analgesic therapy according to collaboration with your
doctor to reduce pain
August 21th, 2019 S: Mr. S said urinated thrice a day
2 PM O: Input: 2500 fluids, Derived from 1500 cc of
intravenous fluids and 1 liter of drinking
The 2000 liquid output comes from 1050cc IWL and
the rest urinates
• There are no signs of excess fluid volume (Edema (-),
Effusion (-))
A: Imbalance of intake and output
P: Continue monitoring for intake and output as well as
monitoring for clinical manifestations of fluid overload
or not
Ineffective S: Mr. S doesn't feel Paretese
Peripheral Tissue O:
Perfusion related to
- defecated smooth 1x / day, consistency of soft stool,
Hipertension
no constipation
-No laceration
-TTV inspection
TD: 130 mmHg
Temperature: 36 C
RR: 20 x breath
PR: 80 x / minute
 A: There is no sign of ineffective tissue perfusion, but
the client is still hypertensive
P: Continue monitoring, collaborating the
administration of tension-reducing drugs (amlodipine)
Acute pain related S: Mr. S complained of postoperative pain
Volume Excess P: Pain when I wake up from sleep
Fluid related to
Q: Pain like being pricked
Compromised
regulatory R: Pain in the scrotum area
mechanisms to post S: 3
surgery
Q: Missing Arises after Post Op
O: The patient looks rowdy
A: The pain scale decreases
P: Continue monitoring pain and continue to provide
analgesic therapy in collaboration with the doctor to
reduce pain
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