NURSING ASSESSMENT

A. ASSESSMENT

1. The identity of the client.

a. The identity of the client
Name : Children S.
Place and date of birth : Tuban, May 3, 2007
Education terahir :-
Religion : Islam
Tribe / Nation : Java
Job :-
Address : JL. Cashew Keprok No. 123 Tuban
b. The identity of the responsible
Name : Ny. I
Place and date of birth : Tuban 19 October 1979
Sex : Female
Education terahir : S1 Economic Accounting
Religion : Islam
Tribe / Nation : Java
Address : JL. Cashew Keprok No. 123 Tuban

2. History of nursing.
Prefix attack: increased body temperature, anorexia and diarrhea occur.
The main complaint: Feces liquid, nausea, vomiting, and decreased body weight
3. Past medical history.
History of illness : No
4. Basic needs.
The pattern of elimination : Frequency CHAPTER more than 4 times with watery
consistency.
Nutrition patterns : begins with nausea, vomiting, causing weight loss patients
5. Physical examination.
a. Pemeriksaan psychological: the general condition seemed weak, high body
temperature, pulse
fast and weak, breathing rather quickly
6. Systematic examination:
Inspection : dry mouth and lips, weight loss, anal redness.
Percussion : Presence of abdominal distension.
Palpation : decreased skin turgor
Auscultation : hearing bowel sounds.

DATA ANALYSIS

NO SIMPTOM DAN SIGN ETIOLOGI PROBLEM

Ds: excessive output Deficit fluid volume &
the elderly client (diarrhea) electrolyte is less than
 say stomach client body needs
bloating, CHAPTER over
4 times a watery consistency

Do:
Percussion: the patient's
stomach
bloating
Palpation: decreased skin
turgor
Inspection: Anal Reddish

TTV:
- N: 110x / min
- S: 390C
- RR: 40 x / min
- Td: 130/90 mmHg
2. Ds: the elderly client Nausea and vomiting. Disturbance needs
said client nutrition is less than
experiencing nausea & body needs
vomiting.

Do:
Percussion: the patient's
stomach
bloating
Auscultation: t er hear
bowel sounds
Inspection: lip client
looks dry & BB
decline.

TTV:
- N: 110x / min
- S: 390C
- RR: 40 x / min
- Td: 130/90 mmHg

B. NURSING DIAGNOSIS

1. Deficit volume of fluid and electrolytes is less than body requirements related to
excessive fluid output (diarrhea).
2. Impaired nutritional needs less than body requirements related to nausea and vomiting.

C. PURPOSE AND CRITERIA RESULTS

 NO DIAGNOSIS
1. Deficit volume of fluid and
electrolytes is less than body
requirements related to excessive
fluid output (diarrhea).
2. Impaired nutritional needs less
than body requirements related to
nausea and vomiting.
D. NURSING INTERVENTION
NO DIAGNOSIS
1. Deficit volume fluid &
electrolytes less than body
requirements related to
excessive fluid output
(diarrhea).
2. Impaired nutritional needs
less than body
requirements related to
PURPOSE CRITERIA RESULTS
Devisit fluid and Signs of
electrolyte dehydration are not
solved in 1 x 24 hours there, mucosal
mouth and lips
moist, well-
balanced fluid
balan
Impaired nutritional Clients increased
needs resolved 1 x 24 nutritional intake,
hours. low dietary
1 portion is
provided, nausea,
vomiting does not
exist.
INTERVENTION RATIONAL
Observation of vital signs TTV capable member
general overview of the
status of client
Observation for signs of The nurse can determine
dehydration the level of dehydration
client.
Measure input and output
of fluid. Adequate fluid intake can
improve the body's fluid
balance.
Provide and encourage Nurses can provide
families to provide drinking appropriate fluid intake
a lot less than 2000 - 2500 with the needs of the
cc per day. client's body.
Collaboration with the Nurses can give liquid
nutrition team in the diet & food according to
provision of low-sodium nutritional needs of the
fluids. client's body.
Assess client's nutritional Nurses can find the
patterns and changes that required level nutrisis
occur. clients.
 nausea and vomiting. Weigh weight loss clients.
Assess the factors that
cause the fulfillment of
nutritional disorders.
Perform physical
examination of the
abdomen (palpation,
percussion, and
auscultation).
Collaboration with a
team of nutrition in
determining the client's
diet.
E. IMPLEMENTATION OF NURSING
NO DIAGNOSIS INTERVENTION
1. Deficit volume of fluid and Observation for signs of
electrolytes is less than body dehydration.
requirements related to
excessive fluid output Observation for signs of
(diarrhea). dehydration.
Measure input and output Measure input and
of fluid. output of fluid.
Provide and encourage
families to provide drinking
a lot less than 2000 - 2500
cc per day.
Collaboration with
physicians in the
administration of fluid
therapy, electrolyte lab
examination.
Collaboration with the
nutrition team in the
provision of low-sodium
The nurse can determine
the level of nutritional
adequacy of the client.
Nurses prevent clients
from doing so.
Nurses can identify the
originator of disturbance
factor nutritional needs
of clients.
Nurses can provide an
appropriate diet with
nutritional needs of the
client's body.
IMPLEMENTATION
Observe vital signs.
Observe for signs of
dehydration.
Provide and encourage
families to provide
drinking a lot less than
2000 - 2500 cc per day.
Collaborate with
physicians in the
provision of fluid
therapy, electrolyte lab
examination.
Collaborate with a team
of nutrition in the
provision of low-sodium

2. Impaired nutritional needs
less than body requirements
related to nausea and
vomiting.
F. EVALUATION OF NURSING
NO DATE DIAGNOSIS
1. October Deficit volume of
30, 2009 fluid and electrolytes
is less than body
requirements related
to excessive fluid
output (diarrhea).
fluids. fluids.
Assess client's nutritional Assess client's
patterns and changes that nutritional patterns and
occur. changes that occur.
Weigh weight loss clients. Considering weight loss
clients.
Assess the factors that Assessing the factors
cause the fulfillment of causing the fulfillment
nutritional disorders. of nutritional disorders.
Perform physical Doing abdominal
examination of the physical examination
abdomen (palpation, (palpation, percussion,
percussion, and and auscultation).
auscultation).
Collaboration with a team Collaborate with a
of nutrition in determining team of nutrition in
the client's diet. determining the
client's diet.
IMPLEMENTATION EVALUATION
Observe vital signs. S: the elderly clients say
the client has no
Observe the signs stomach bloating and
dehidras. bowel movements 1
Measure input and time a day.
output of fluid.
O:
Provide and encourage Percussion: stomach
families to provide client has not
drinking a lot less than bloating
2000 - 2500 cc per day. Palpation: turgor
Collaborate with normal skin
physicians in the Inspection: Anus
provision of fluid no longer
therapy, electrolyte lab redness.
examination.
Collaborate with a team TTV:
of nutrition in the - N: 100x / min
provision of low-sodium - S: 36.50 C
fluids. - RR: 20 x / min
- Td: 110/70 mmHg
 A: The problem is
resolved in a 1 x 24
hours
Q: The action halted
2. October Impaired nutritional Assess client's S: the elderly clients say
30, 2009 needs less than body nutritional patterns and clients have no nausea
requirements related changes that occur. and vomiting again.
to nausea and
vomiting. Considering weight loss O:
clients. Percussion: the
Assessing the factors patient's stomach was
causing the fulfillment not bloated anymore.
of nutritional disorders. Auscultation: no
Doing abdominal longer audible bowel
physical examination sounds
(palpation, percussion, Inspection: client lips
and auscultation) look fresh & BB is still
Collaborate with a team the same.
of nutrition in
determining the client's TTV:
diet. - N: 100x / min
- S: 36.50 C
- RR: 20 x / min
- Td: 110/70 mmHg

A: The problem has

been resolved partially
in 1 x24 hours
Q: The action continues