NAME: NAILA FERDIA PUTRI

CLASS: 3B
NIM: 1130019059
            
UTS ENGLISH
Case 
Kids B admitted to hospital in a room Hajir ismail with complaints of diarrhea 7x liquid
consistency, slimy, skin turgor kurag 2 seconds, sunken eyes, a special noise
increases. Sometimes px grinned while holding his stomach. From the results of physical
examination, it is known that the peristaltic frequency is increased, biising
the intestinal hyperactivity. Anamesa results show that px previously ate salad with
their mother. From the results of the diagnostic examination, electrolyte levels still show
normal, how is the nursing care px?
P E NG K A J I A N    
1. Client Demographics   
a) Client Data Name: Child B Age: 13 Years  
Gender: Female Address: Wonokromo
Hospital Entry Date : May 6 , 2020 Room: Hijir Ismail
Medical Diagnosis: Diarrhea
 Medical Register No: 432126 Date of Assessment : 7 May 2020
b) Data of Person in Charge Name: Ny. A  
Age: 35 Years
  Hub with Clients: Mother
 2. Medical History   
a) Reasons for admission to hospital  
After eating salad with his mother, the patient complains of diarrhea 7x the
consistency of liquid, mucus, skin turgor for less than 2 seconds, sunken eyes, increased
bowel sounds, sometimes the patient grins while holding his stomach.
b) Main Complaints  
7x diarrhea and abdominal pain
c) History of Health At It  
Diarrhea 7x the consistency of liquid , slimy, skin turgor less than 2
seconds, sunken eyes , increased special noise , abdominal pain .
d) History of Health Masa Then  
  The client has never experienced this before
e) Family Health History  
The client says that no family has the same disease
3. Physical examination   
a) General appearance  
  Awareness: The client seems limp
b) Vital signs
BP : 110/90 mmHg
 N: 85x / minute  
RR: 20x / minute
 S: 36,5 ° C
Weight: 48 kg
  Stool: Liquid, frequency 6-7x / day
c) Focused physical examination.
Eyes : Sunken eyes  
Mouth: Dry lip mucosa.
Abdomen: Abdominal distension
-Aukultation: hyperactive bowel sounds 20x / minute Integument: skin turgor> 2
seconds
 4. Biological Data  

No. Activity House Hospital

1. Nutritional 3x / day 3x / day

Pattern: the portion runs out
 
-Frequency of
eating
- Meals 5 tablespoons

2. Elimination   2 × / day
Pattern:
 
-BAK
- Chapter > 7x / day

 NURSING DIAGNOSIS   
Diarrhea associated with gastrointestinal irritation and malabsorption evidenced by the
patient said before eating salad, diarrhea 7x consistency
of liquid, noisy bowel increases, painful abdomen, turgor less than 2 seconds, and the
eyes sunken
INTERVENTION    

No Data analysis Diagnosis Result Criteria Intervention

.
1. Subjective data D.0020 L.04033 I.03101
  The client said      
before eating
Category: physiologica After 1x24 hours of Observation:
salad with his
l nursing action, it is
mother, then - Identify the causes
expected that faecal
diarrhea was 7x Subcategory: nutrients of diarrhea         
elimination will improve
the consistency and fluids.
with the following - Identify the history of
of liquid,
Diarrhea is associated criteria: feeding         
sometimes
with gastrointestinal
grinning while a) Pain      - Monitors stool color,
irritation and
holding his volume, frequency, and
malabsorption as Abdom en from
stomac consistency         
evidenced by the increasing (2) to
Objective data patient saying he decreasing (5) - Monitor the amount
previously ate salad, of diarrhea
•Turgor b) Stool consistency fro
diarrhea 7 times the spending         
m
skin less than 2 consistency of
- Monitor the safety
the liquid, increased      slice (1) into shape (5)
second of food preparation         
bowel sounds,
c) Frequency of
•Eye abdominal pain , less Therapeutic:
detection from
turgor.
sunken worsening (1) to - Set up a path
of 2 seconds, and becoming more (5)
•Noisy  intervention
sunken eyes
d) Intestinal peristalsis
intestines - Give oral fluids intake
from worsening (1) to
increased enlarging (5) Education:
hyperactivity - Encourage small,
frequent meals in stages
• Frequency
- Encourage avoiding
peristaltic
gas- forming , spicy and
increased lactose-containing foods
•Frequency
CHAPTER clients
more than 7x /
 day consistently
the liquid
•Frequency
TAK client
2x / day
•Client
I lost weight
body
•TTV client:
TD: 110/90
mmHg
N:
85x / minute
RR:
20x / minute
S: 36.5 ° C BW:
48 kg

 
IMPLEMENTATION         
 

No. Date & Time Implementation Initials

1. 08-05-2020 Observing TTV: Room service nurse

  08.00 WIB TD: 110/90 mmHg  

    N: 85x / minute  

    RR: 20x / minute  

    S: 36.5 ° C  

  08.15 WIB Measure united bodies  

patient
    Weight: 48 kg  

  08.30 WIB Doctor's vision  

  09.00 WIB Provide medication accordingly  

doctor's advice
    Response: The patient  
responds well and listens to
the nurse how to use the drug

09.10 WIB
Provide injection of drugs and
fluids through the IV according
to the doctor's advice
Response: the client is willing
to be injected
09.30 WIB
Monitor for 24 hours
EVALUATION    

No. DATE & TIME EVALUATION

1. 08-05-2020 S:
  14.00 -Patient said the frequency
of bowel movements in a day began
to decrease and improve
    -the patient said his bowel was no longer liquid

    - the patient says his stomach doesn't hurt
anymore

    - the patient says his appetite is still decreased

    O:

    -The patient's general condition has improved

considerably
    -TTV is within normal limits
TD : 120/60 mmHg N: 86x / min
RR: 18x / minute S: 36,5 ° C
A: The problem is partially resolved

P: planing continued