NURSING CARE

IN PATIENTS WITH DIAGNOSTIC MEDICAL Ny.K GASTROENTERITIS

A. ASSESSMENT
Date of assessment : 15 feb 2016
Space : manliness 3
Hours : 09:15
No. medical records : 162 127
Diagnosis in : Gastroenteritis
1. IDENTIFICATION OF CLIENTS

Name : Ny.K
Age : 65 Years
Gender : Female
Religion : Islam
Education : Elementary school
Occupation : Housewife
Tribe / nation: citizen
Address : jl.K 5 T Madiun
Marital status: Married
2. RESPONSIBLE CLIENTS

Name :Tn.S
Age : 44 Years
Gender : Male
Education : SPD
Occupation : Employee
Relationships with patients : Children
Address : Jl.K no.5 t Madiun
B. ASSESSMENT OF HEALTH HISTORY

• Main complaint

Said his client felt weak when the activity or rest.

• Disease History Now

Clients said that two days before the MRS body limp, diarrhea 2x, 1x vomiting,
dizziness spinning, do not want to eat. When the assessment is still feeling saaat
 clients arrive activity '' His whole body felt weak terutamaa the foot and hand, the
clients rest when tired and assisted by keluarga.hal activity is due to decreased fluid
intake.

• Past medical history

Clients say never suffered from heartburn for two years now, the treatment is done
by taking medicine that is usually at the nearest shop to buy medicine drug name is
Promag.

• Family Health History

The family said the client has no history of disease experienced by clients today.

 Genogram

C. Examination
1. Vital Signs

S: 360C N: 70 x / mnt T: 130/90 mmHg RR: 20 x / min

General Situation: weak

Patient Awareness: composmentis

2. Assessment of respiratory (B1)

- While the assessment did not complain tightness
- Irregular heart rhythm
- Type of normal breathing
- The breathing vesicular
- MK: not appear nursing problems
3. Assessment of circulatory / cardiovascular (B2)
- Regular heart rhythm and complained of chest pain
- Abnormal heart sound
- CRT: 3 seconds
- Akral: warm
- MK: No
4. Assessment neurosensory / persyarafan (B3)
- GCS: 456
- When the client says dizziness assessment.
- Sclera anemic
- Conjunctival pallor
- No problem visual disturbances, hearing and smell
- Clients break / tidut> 8 hours / day
- MK: lack of fluid volume
5. Assessment of elimination / Urinal (B4)
- When the client says BAK normal assessment 3-4x / day
- Production of urine is <1000 / day
- Clear yellow color
- The smell of ammonia
- MK: There is no problem of nursing
6. Assessment of food and fluids / digestion (B5)
- Dirty mouth
- Dry mucosa
- When in the assessment of client says there is no problem with the throat and
abdomen, but the client has not CHAPTER last date 25-01-2014
- Decreased appetite
- Eat Hannya 3 tablespoons
- MK: less nutritional imbalance of needs associated with inadequate food intake.
7. Assessment of musculoskeletal and integument (B6)
- Free joint movement
- Muscle Strength 5 5
- 55
- Less elastic skin turgor
- Dry skin
- MK: the risk of fluid volume deficiency.
8. Assessment of the endocrine system
- Any enlargement of the thyroid gland and lymph nodes
- MK: There is no problem of nursing
9. Personal Hygine and Greatness
- Client spotted and discipline 2x / day
- Change clothes 1x / day
- Do not wash or brush your teeth
- MK: Self-care deficit, hygine
10. Psychosocial Assessment
- The client said that the pain suffered punishment because of the pain created by the
act of its own clients
- The client's behavior against the illness tend to be moody / silent
- The client was very cooperative when interacting
- MK: There is no problem of nursing.
11. Assessment spiritual
- Habit worship
- During the ill client never worship
- Before the ill client diligent worship
- MK: Barriers religious b.d sosikultural lack of interaction.
12. Drug Therapy
- Infuse RL 30 MDGs
- Cefotaxime 3x1
- Vomcerun 3x1
- Per oral: - unalium 2x5 mg
- -lanzoprazo 2x1
- -Biodiar 3x1 tab
13. Investigations (28-01-2014)
- Haematology
- BBS / LED: 38 (L: 0-15 / p: 0-20 mm / h)
- The level of sugar
- BSN: 70 (70-110 mg / dl)
- 2JPP: 140 (<125 mg / dl)
- Profile of fat
 Cholesterol: 131 (<200 mg / dl)
 HDL: 34 (> 35 mg / dl)
 LDL: 85 (<150 mg / dl)
 Triglicerid: 140 (<150 mg / dl)
- electrolytes
 Sodium: 149 (135-155 m mol / L)
 Potassium: 4.1 (3,5- 5,5 m mol / L)
 Chloride: 101 (98-107 m mol / L)
 Calcium: 2.37 (2.3 to 2.8 mmol / L)
- LFT
 Bill D: 0.14 (<0.25 mg / dl)
 Bill T: 0.35 (<1.0 mg / dl)
 AST: 31.6 (L: 36 / P: 31 n / L)
 ALT: 20.7 (L: 40 / P: 31 n / l)
 Tot prot: 6.67 (6.6 to 8.79 g / dl)
 Albumin: 3.84 (3.6 to 5.2 g / d)
 Globulin: 2,83 (2,6 - 3.6 g / d)
- RFT
 Creatinine: 0.98 (L: 0.8 to 1.5 / P: 0.7 -1.2)
 Bun: 9.9 (Bun: 4.7 to 23.4 / urea: 10- 50 dl)
 Uric acid: 3.8 (L: 3,1 -7,0 / P: 2.4 to 7 mg / dl)
 DATA ANALYSIS

DATE DATA ETIOLOGI ISSUES

27 jan Ds : the client says her body inadequate dietary Lack of fluid
2014 limp intake of nutrients volume
Do :
- general state was limp
- skin turgor less elastic
- dry skin
- sclera anemis
VS
-T : 130/90 mmHg
-N : 70 x/mnt
-RR: 20 x/mnt
-S :360C
- dry mucuous
- decreased urine output

27 jan Ds : the client says do not inadequate dietary Impaired lack of

2014 want to eat, eat spotted and 3 intake of nutrients demand
tablespoons
Do :
- mouth stink
- dry mucuous
-VS
T : 130/90 mmHg
N: 70 x/mnt
R : 20 x/mnt
S : 36 0C

Priority Nursing Diagnosis

1. Risk lack of fluid volume decline b.d oral fluid intake

2. Nutrition lack of demand b.d inadequate food intake

 NURSING INTERVENTION

NO Day/date Nursing Diagnosis NOC NIC

1 Monday Risk lack of fluid Having given 1.monitor Vital sign
.15 feb volume decline b.d nursing care for 2. increase 1-2 glasses of
2016 oral fluid intake 3x30 min client is fluids orally every 24 hours
able to fulfill the 3. observasi sign ''
needs of adequate dehydration
fluid volume with 4. colaboration with the
the criteria results medical team in the delivery
my good of infusion fluid therapy
-Turgor Skin less
elastic
-sclera morbidly
anemic
- normal vital sign
-moist mucuous
-Leather moist
2 Monday, Nutrition lack of Once granted 1. keep oral hygiene can
15 feb demand b.d 1x24 hour nursing increase appetite
2016 inadequate food care for clients
intake 2. can be met metabolism of
can fulfill the
nutritional needs nutrients as needed
of the criteria 3. the food varied can
results: increase appetite
- Fine dondition 4. give intake of diet /
- moist mucous nutrition proper

- normal vital sign

 IMPLEMENTATION
Shift Day/date Nursing Diagnosis Time IMPLEMENTATION Response Signature

Morning Monday, Risk lack of fluid 08.00 1.monitoring Vital 1. S: 36 0 c

15 feb volume decline b.d a.m sign N :70x/mnt
2016 oral fluid intake 2. increase 1-2 glasses T:130/90 mm
Hg
of fluids orally every
Rr : 20x/mnt
24 hours 2. the client
3. observing sign '' will attemp
dehydration increase fluid
4. colaborating with piecemeal
the medical team in 3. client tense
the delivery of moment in
infusion fluid therapy injection.

Morning Monday, Nutrition lack of 08.00 1. advocate to keep 1.The client

15 feb demand b.d a.m oral hygiene can brush teeth 1x
2016 inadequate food increase appetite / dayI
intake 2. The client
2.explain to be met will try to
metabolism of spend eating,
and eat little
nutrients as needed
but often
3. motivating about 3. clients want
the food varied can to eat a varied
increase appetite diet of soy
porridge sprit
4.collaborate to give
intake of diet /
nutrition proper
 EVALUATION

Shift Day/Date Nursing TIME EVALUATION Signature

Diagnosis
Morning Monday, Risk lack of fluid 14.00 S : the client says her body
15 feb volume decline improved enough
2016 b.d oral fluid O:
-general state enough
intake
-skin turgor less elastic
-sclera anemis
-VS
Td :130/85 mmHg
N : 72 x/mnt
R : 20 x/mnt
S : 360 C
A : The issue is resolved in
part
P : continue intervention 1,2
and 4
Morning Monday, Nutrition lack of 14.00 S: the client says that
15 feb demand b.d increase appetite
2016 inadequate food O:
intake - mouth pretty smelling
- dry mucous
VS
T :120/80 mm Hg
N :75 x/mnt
RR:20 x/mnt
S :36 0C
A: problem solved partially
P: intervention in submitting
1 and 4