BAHASA INGGRIS

“ASSESSMENT OF INFECTIOUS GASTROENTERITIS PATIENT ”

Disusun Oleh :

ARTHA SITA VELLA PRATIWI

1614401098

TINGKAT II REGULER 2

POLITEKNIK KESEHETAN TANJUNG KARANG

JURUSAN D3 KEPERAWATAN

TAHUN 2017/2018
 Assessment of infectious gastroenteritis patients (Diarrhea)

Assessment date : On march 16th , 2018.

Hour assessment : At 07.00 pm.
Room : Kenanga
Registration Number : 001
Date of hospitel admission : on march 14th ,2018

A. Patient Identity
Name : Mrs. B
Age : 63 years old
Gender : female
Religion : islam
Education : junior high school
Occupation : farmers
Blood type : A
Address : Swadaya street of 9 number 23

B. The identity of the person in charge of the patient

Name : Mrs. C
Age : 45 years old
Gender : female
Occupation : teacher
Address : swadaya street of 9 number 23
Relationship with patient : the sister of patient

2. lementation prominent
 The patient went to Abdul Moeloek Hospital on March 14th , 2018 . She said
the she feel stomach ache and weak. She said poop more than 5 times per day.

 Lementation prominet when assessment

 When assessment on March 16th , 2018. She said that she feel stomach ache
and weak.

 Health history now

On march 10th , 2018. She said that she poop more than 5 times per day. She
said the she feel stomach ache and weak.

 Health history in the past

Patien have never been hospitalized for infectious gastroenteritis.

 Family health history

The pasient family has not history of infectious pain.

Needs Assessment
1. Oxygen Needs
At home : she said she can breathe normally, and there is no difficulty to
breathe.
At Hospital : she don’t have respiratory distress, her respiration rates are
18 times /minute.”

2. Nutrients and fluids :

At home :
patient eats rice 3 times per day with medium portion. Drink 6 – 8 glasses
At hospital :
Patient eats 3 times per day with small portions. Patient only drink
enough water

3. Elimination urination and defacete

At home :
patient urinations 5 – 6 times per day and patient defacete 1 – 2 times per
day.
At hospitel :
Patient urinations 4 – 6 times per day and patient defacete 5 – 6 times per
day.
 4. Patient of rest and sleep:
At home :
Patients sleep 6 – 8 hours per day.
At hospital :
patient only sleep 3 – 4 hours per day and often wake up.

5. Activity Needs
At home : she can activity like as work.
In hospital : she can’t activity as usual , she can’t working.
6. Patterns of self health
At home :
patient bathing twice a day shampooing and brushing teeth.
At hospital :
Patient only take one shower per day.

7. Religion Needs
At home : she prayed in time.
At hospital : he rarely praying, because her body is weakness.

3. General condition
A. Awareness level : coomposmentis
Eye : 4
Verbal : 5
Motorik : 6

B. Vital sign
Blood pressure : 120/90 mmHg
Temprature : 37° C
Pulse : 92 times/minute
Respiratory : 32 times/minute
C. General appearance : the patien appears weak.

D. Physical checkup :

1. Head : simetris shape , no dirt , black short patient hair. Scale clean no lesions ,
no tumors and no tenderness.

2. Eye : simetris shape , sunken and conjunctival anemis.

3. Nose : simetris shape and no injuries.

4. Mouth : sianosis lips and simetris shape

5. Ear : simetris shape and without serum inside

6. Neck : no injuries and the is no enlarged distension of the jagular vein.

7. Chest :
A. inspection : symetrical shape and no injuries, chest shape normal, no trouble
breathing.
B. palpate : there is no tenderness and no lumps.
C. percussion : sonor voice
D. auskultration : no additional sound and no wheezing sound.

8. Abdomen
A. inspection : symetrical shape , no injuries and lesi
B. palpate : pressure pain in 4 quadrant, and quadrant 3 and 4 have tenderness.
Scale of patient pain 4.
C. percussion : hypertimpani voice
D. auskultration : bowel sound increases 34 times per minute.

9. Extermittes : symetrical shape , no injuries and disbility.

10. Integumen : white caor , turgor is hard to come back.

 11. Genatalia : not installed catheter and no injuries.

SUPPORTING DATA

HEMATOLOGY PRODUCE NORMAL

Hemoglobin 12 12-14 g/dl
Leukocytes 5800 5000-10.00 g/dl
Hematokrit 29 37-43 g/dl
Trombosit 350.000 150.000-400.000/uL
Basofil 0 0-1%
Eosinofil 2 1-3%
Limposit 56 20-40%
Monosit 4 2-8 %

Drugs Therapy :
1. Infusion RL 15 tpm (750 cc) to replace lost body fluids.
2. Novalgin injection 3 x 1 amp (metampiron 500 mg/ml.
3. Injections of ulsikur 3 x 1 amp (simetidina 200 mg/2ml)
4. Cefptaxime injection 3 x 1 amp (sefotaksim 500 mg/ml)

DATA ANALYSIS
Name : Mrs. B Register Number : 001
Age : 63 years old Space : Kenanga

NO. ASSESMENT ETIOLOGY PROBLEM

March 16th, Subjective Data : Excessive output Disruption of fluid
2018 1. Mrs. B says : balance
“greenish yellow
defacate mixed with
mucus”.
Objective Data :
1. Turgor skin
decreased dry mouth
 and lazy eating.

Subjective Data : hyperperistaltic Discomfort and pain

1. Mrs. B says: ” that
having a flatulence
Objective Data:
1. After percussion
known client
distensi. Client
seemed to hold the
pain peristaltic
movement 34 times
per minute. Pain
feels like squeezed
and often. Scale of
patient pain 4.

Subjective Data : Bacterial infection Defaction

1. Mrs. B says:” that elimination disorder
chapter more than 5
times per day.
Objective Data :
1. Client appears weak
and conjunctival
anemic

NURSING DIAGNOSIS

1. Disruption of fluid balance related to excessive output

2. Discomfort and pain related to hyperperistaltic
3. Defaction elimination disorder related to bacterial infection