Nursing in Patients with gastroenteritis

A. Assessment

Systematic assessment includes data collection, data analysis and problem determination. The collection
of data obtained by means of intervention, observation, psikal assessment.

Assessment of data by Cyndi Smith Greenberg, 1992 are:

The identity of the client.

History of nursing.

Prefix attack: Originally whiny child, anxiety, increased body temperature, anorexia and diarrhea occur.

The main complaint: the more liquid Faeces, vomit, if losing a lot of water and electrolytes occur
symptoms of dehydration, body weight decreased. In infants sunken fontanel large, tone and reduced
skin turgor, mucous membranes of the mouth and lips dry, CHAPTER frequency more than 4 times with
watery consistency.

Past medical history.

History of the illness, history of immunization.

Family psychosocial history.

Treated will be a stressor for the child itself and for the family, the anxiety increases if the parents do not
know the procedure and treatment of children, after realizing her illness, they will react with anger and
guilt.
Basic needs.

The pattern of elimination: will change the BAB more than 4 times a day, BAK few or rare.

Nutritional pattern: beginning with nausea, vomiting, anopreksia, causing weight loss patients.

The pattern of sleep and rest will be disturbed because of abdominal distension that would cause
discomfort.

Pattern hygiene: bathing habits every day.

Activities: will be disturbed because the body is very lamah and the pain due to abdominal distension.

Physical examination.

Psychological examination: general condition seemed weak, kesadran composmentis to coma, high body
temperature, rapid and weak pulse, breathing rather quickly.

Systematic examination:

Inspection: sunken eyes, large fontanel, mucous membranes, mouth and dry lips, weight loss, anal
redness.

Percussion: presence of abdominal distension.

Palpation: less elastic skin turgor.

Auscultation: bowel sounds hearing.

Examination tinglkat growth and development.

Diarrhea in children will experience disruption due to child dehydration so that body weight decreased.

Investigations.

Stool examination, complete blood and doodenum intubation is to find the cause of the quantitative and
qualitative.

B Nursing Diagnosis

Volume of fluid and electrolyte deficit is less than body requirements related to excessive fluid output.

Impaired nutritional needs less than the body needs berhubuingan with nausea and vomiting.

Impaired skin integrity related to the irritation, the frequency of excessive CHAPTER.

Impaired sense of comfort pain associated with abdominal distension.

Lack of knowledge related to the lack of information about illness, prognosis and treatment.

Anxiety associated with separation from parents, a scary procedure.

C. Intervention

Diagnosis 1.

Volume of fluid and electrolyte deficit is less than body requirements related to excessive fluid output.

Objectives:

Devisit fluid and electrolyte resolved

Criteria results:

Signs of dehydration are not available, oral mucosa and lips moist, well-balanced fluid balan

Intervention

Observation of vital signs. Observation for signs of dehydration. Measure infut and output of fluid
(balanc ccairan). Provide and encourage families to provide drinking a lot less than 2000 - 2500 cc per
day. Collaboration with physicians in providing therafi fluid, electrolyte lab examination. Collaboration
with the nutrition team in the provision of low-sodium fluids.

Diagnosis 2.

Impaired nutritional needs less than the body needs berhubuingan with nausea and vomiting.

Objectives:

Impaired nutritional needs resolved

Criteria results:

Clients increased nutritional intake, diet out 1 portion of which is provided, nausea, vomiting does not
exist.
Intervention:

Assess client's nutritional patterns and changes that occur. Weigh weight loss clients. Assess the factors
causing the fulfillment of nutritional disorders. Perform physical examination of the abdomen (palpation,
percussion, and auscultation). Give a warm conditions and diet in small portions but frequently.
Collaboration with a team of nutrition in determining the client's diet.

Diagnosis 3.

Impaired skin integrity related to the irritation, the frequency of excessive CHAPTER.

Objectives:

Impaired skin integrity resolved

Criteria results:

Skin integrity returns to normal, no irritation, signs of infection does not exist

Intervention:

Replace the child if the diaper is wet. Clean the buttocks slowly soap non alcohol. Give zalp such as zinc
oxsida if there is irritation of the skin. Observation of the buttocks and perineum of infection.
Collaboration with physicians in providing therafi antipungi as indicated.

Diagnosis 4.

Impaired sense of comfort pain associated with abdominal distension.

Objectives:
Pain can be resolved

Criteria results:

Pain can be reduced / hiilang, calm facial expression

Intervention:

Observation of vital signs. Assess the level of pain. Set a comfortable position for the client. Give a warm
compress on the area abdoment. Collaboration with physicians in providing therafi analgesics as
indicated.

Diagnosis 5.

Lack of knowledge related to the lack of information about illness, prognosis and treatment.

Objectives:

Increasing family knowledge

Criteria results:

Client families with the disease process client horrible, calm facial expression, many families are not
asked again about the client's disease process.

Intervention:

Assess client's level of family education. Assess the level family knowledge about the disease process
client. Explain about the disease process with the client through penkes. Provide opportunities for
families when there is not incomprehensible. Involve families in the provision of action on the client.
Diagnosis 6.

Anxiety associated with separation from parents, a scary procedure.

Objectives:

The client will show decreased levels of anxiety

Intervention:

Assess the client's anxiety level. Kaji trigger anxiety. Create a schedule of contacts with clients. Assess the
desirability of the client. Give your favorite toy as a client. Involve families in every action. Encourage the
family unrtuk always accompany clients.

D. Evaluation

The volume of fluid and electrolytes returned to normal as needed.

Nutritional needs are met in accordance kebutuhantubuh.

Skin integrity back noprmal.

Sense of comfort are met.

Knowledge ancestry increases.

Anxious in client is resolved.

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