NURSING CARE

BASIC HUMAN NEEDS

Gastroenteritis On Patient An. N at Dahlia Ward

Arranged by:

Frida Suryani (P1337420417023)

Antasena 1

POLTEKKES KEMENKES SEMARANG

DIII NURSE of MAGELANG

2018
 BAB II

CASE REVIEW

Date of entry : January 11, 2018

Entry hours : 22:00 pm

Date of assessment : January 12, 2018

Hours of assessment : 09.00 WIB

Ward : Dahlia

Hospitals : RSUD Tidar Kota Magelang

No RM : 219952

Medical diagnosis : Gastroenteritis with Dehydration

A. Assessment

1. Client Identity

Name : An. A

Age : 19 months

Gender : Female

Religion : Islam

Address : Ngampel, Salaman

2. Person in charge

Name : Ny. R

Age : 29 years old

Gender : Female

Religion : Islam

Job : Housewife
 Address : Ngampel, Salaman

Relationship with client: biological mother

3. Medical history

a. Main complaint

2x defecate from 07.00-09.00 WIB, there is a little dregs, color to brass, slimy,
and no blood.

b. History of the disease now

Client came to the RSUD Tidar Magelang on 11 January 2018 at 22.00 WIB,
because got referral from Kauman Salaman clinic with 10x diarrhea, decreased
drinking desire, nausea and vomiting 3x, client complaint since morning,
urination client last day, temperature 39° C, defecate liquid and dregs little, no
mucus, no blood, no abdominal pain, An. A does not want to eat and drink.

c. Past medical history

Previous clients have never been hospitalized. The client has no allergy
medicines / food. The client has no seizure history.

d. Family disease history

The client's mother said in the family no one is suffering from hereditary or
contagious disease.

e. History of growth
BB: 9.9 kg
TB: 78 cm
Head circumference: 54 cm
Upper arm circumference: 18 cm

4. Physical examination

a. General situation: weak

b. Vital signs: pulse 96x / min, temperature 36.1° C, RR 20X / min
c. Eyes: the conjunctiva is not anemic and sclera is not ipteric
 d. Skin: skin turgor <2 s, CRT <2 s
e. Abdomen:

I: flat stomach, no lesions

A: intestinal peristaltic 27x / min
P: hypertimpani
P: no tenderness

f. Anus: no lesions, redness, irritation and moisture.

5. Therapy program

a. Inf asering 20 tpm

b. Liprolac 2x1 sachet
c. Zink syrp 1x1 cth
d. Promuba syrp 3x1 cth
e. Paracetamol syrp 4x1 cth
f. Pct syrp 4x1 cth

B. Data Analysis

NO Date/time Data focus Etiology Problem

1. 12/01/18 SD: The client's mother says the Loss of Lack of

10.20 WIB child is defecated 2x from 07.00- abnormal fluid

09.00 WIB. There are dregs, slimy, fluid volume
yellow, tub last day. (diarrhea)
OD: moist lips mucosa, skin turgor due to
<2 s, client limp, intestinal infection
peristalsis 27x / min, leukocyte
11,8 10^3 / uL

2. 12/01/18 SD: The client's mother says the Inadequate The

10.25 WIB client's appetite is diminished, intaxion and nutrition

eating the half-serving RS porridge output al
and 2x diarrhea in 2 hours. imbalanc
OD: BB before and sick same. e is less
 client limp, intestinal peristaltic 27x than the
/ minute. need

C. Nursing Diagnoses

NO Nursing Diagnoses Date found Date resolved

1. Lack of fluid volume associated with 12/01/2018 14/01/2018

abnormal fluid loss (diarrhea) due to
infection is characterized by leukocyte
11,8 10^3 / uL, 2x liquid defecate in 2
hours, drink 1 glass / day, skin turgor <2 s,
client seems weak.

2. Nutrition imbalance is less than body 12/01/2018 14/01/2018

needs related to inadequate intake and
output is characterized by decreased
appetite, consuming ½ portion, 2x liquid
defecate in 2 hours, drink 1 glass / day,
client seems weak.

D. Nursing Plan

Date/time NO DK Objectives And Yield Intervensi

Criteria

12/01/2018 I After a 3x8 hour nursing 1. Monitor hydration

action is expected the status and fluid
10.40 WIB
problem of fluid volume loss.
deficiency can be resolved R / gives
with the results criteria: information of
fluid loss and
1. indicates fluid
 balance decreased fluid
2. vital signs are within volume causing
normal limits tissue drought.
3. Adequate oral intake Fluid replacement
guidelines.
2. Monitor vital
signs.
R / know the
client's condition
and prevent
complications.
3. Encourage families
to help clients eat
and drink.
R / replace the lost
oral electrolyte
solution.
4. Monitor intake and
output.
R / provides fluid
and nutritional
balance
information and
facilitates fluid
replacement and
nutrients.
5. Collaboration with
doctors in granting
liquid IV and
antibiotic therapy
program.
R / fluid
 replacement that
has been lost to the
client. Antibiotics
are given due to
infection.

12/01/2018 II After a 3x8 hour nursing 1. Monitor nutritional

action is expected the input
10.45 WIB
problem of nutritional R / measure the
effectiveness of
imbalance is less than the
nutrition and fluid
body needs resolved with the
support.
results criteria:
2. Monitor signs of
1. Not happening malnutrition
weight decreasing R / affects diet and

means increases nutrient

2. Client spended diets intake and

acknowledges
provided
malnutrition.
3. There is no
3. give food in small
malnutrition signs
portions but often
and increase
accordingly.
R / increase food
input
4. Collaboration with
nutritionists to
determine TKTP,
low fiber.
R / protein for
healing of tissue
integrity. Low fiber
decreases intestinal
peristalsis.
E. Nursing Note

Date/time No Implementation Response

DK

12/01/2018 I 1. Monitor SD: The client's mother says

09.10 WIB hydration status the child defecates 2x from 7
and fluid loss o'clock . There is mucus, there
is dregs.

OD: Mucous membrane of

moist lips and skin turgor <2 s.

09.15 WIB 2. Monitor vital SD: The client's mother said

signs and bowel the child is not afraid.
sounds
OD: Pulse 96x / min
,temperature 36.1° C, RR 20X /
min, BU: 27x/min.

09.20 WIB II 3. Monitor signs of SD: The client's mother says

malnustrition that the client is not nauseated
and vomiting but decreased
appetite.

OD: Client seems weak,

cranky and dry skin.

09.25 WIB 4. Encourage SD: The client's mother said

mothers to feed a "yes".
little but often OD: The client's mother seems
willing and will do.

11.45 WIB II 5. Provide clients SD: The client's mother said

with low-fiber thank you.
and low-fiber
OD: The client does not seem
diets and
to want to eat, must be with the
 collaborate with streets.
nutritionists

12.15 WIB 6. Giving promuba SD: The client's mother says

syrp 3x1 cth and the child is fussy and hard to
pct syrp 4x1 cth. take medication.

OD: The client seems

unwilling to take medicine.

12.15 WIB 7. Encourage SD: The client's mother said

mothers to the child is still not appetite.

encourage OD: The client's mother

seemed willing.
children to eat
and drink.

F. Progress Notes

Date/time No. DK Progress Notes (SOAP)

12/01/2018 I S: the client's mother said 4x liquid bowel movements,

14.10 WIB there was dregs, there was mucus, not bloody, and
yellow.

O: pulse 96x/min, temperature 36,1°c, rr 20x/min,

moist lips mucosa, skin turgor <2s, leukocyte 11,8 10^3
/ ul, hb 10,2 g/dl.

A: the problem of fluid volume shortages is partially

resolved.

P: continue intervention, hidrasi status and liquid

standards, vital signal monitors, inputs and output
monitors, collaborate with doctrating iv and therapy
 programs.

14.10 WIB II S: The client's mother said the client was not nauseated
and vomited, but less appetite, spent 1/2 portion,
drinking water, and ASI ±200 cc.

O: Weight 9,9 kg, damp skin, strong hair, red and clean,
clients seem weak.

A: The problem of nutrient imbalance is less than the

body needs is partially resolved.

P: Continue the intervention, monitor nutritional intaks,

monitor malnutrition markers, feed often but little,
collaborate with nutritionists in giving TKTP and low
fiber diets.