A NURSING CARE FOR CHILDREN WITH DIARRHEA DISEASES

Savina Tunnaja (P1337420520079)

Eva Fitriana (P1337420520080)
Evi Fitrianti (P1337420520081)
Satya Aji Prihutama (P1337420520082)
Meita Ratri Nugraheni (P1337420520083)
Bagas Surya Setyawan (P1337420520085)
Annisa Prajna Muthi (P1337420520086)
Wijdan Alya Salwa Shabrina(P1337420520087)
Tusi Wahyaning Pangesti (P1337420520088)
Febri Finandita (P1337420520089)
Hanindia Nurul Atikah (P1337420520090)
Lita Elisa (P1337420520091)
Setyaki 2

POLYTECHNIC OF THE MINISTRY OF HEALTH, SEMARANG

MAGELANG NURSING PROGRAM D III

ACADEMIC YEAR 2020/2021

 BASIC CONCEPTS OF DIARRHEA

A. DEFINITIONS

Understanding Nursalam (2008), says diarrhea is basically the frequency of bowel

movements that are more frequent than usual with a more watery consistency. Diarrhea is a
bowel disorder or defecation characterized by defecating more than 3 times a day with a
consistency of liquid stool, can be accompanied by blood or mucus (Riskesdas, 2013). Diarrhea
is a disease that occurs when there is a change in the consistency of the stool. A person is said to
suffer if the stool is watery than usual, and if the bowel movements are more than three times, or
the bowel movements are watery but do not bleed within 24 hours (Dinkes, 2016). WHO (2009)
states that diarrhea is a state of defecation with a soft to runny consistency and a frequency of
more than three times a day. Acute diarrhea lasts for 3-7 days, whereas persistent diarrhea lasts
for more than 14 days.

 Classification

Guidelines from the Laboratory / UPF Child Health Sciences, Airlangga University in Nursalam
(2008), diarrhea can be grouped into:

1. Acute diarrhea, which is diarrhea that occurs suddenly and lasts 3-5 days at most.
2. Diarrhea is prolonged because diarrhea lasts more than 7 days. 11
3. Chronic diarrhea if diarrhea lasts more than 14 days.

Chronic diarrhea is not a unitary disease, but a syndrome whose causes and pathogenesis are
multi-complex. Considering the many possible diseases that can cause chronic diarrhea and the
many examinations that must be done, this literature review is made to be able to carry out more
targeted examinations. Meanwhile, according to Wong (2008), diarrhea can be classified as
follows:

 Acute diarrhea

Is the main cause of illness in toddlers. Acute diarrhea is defined as an increase or change in
frequency of defecation that is often caused by an infectious agent in the infectious
gastroenteritis (GI) tract. This situation can accompany an upper respiratory tract infection (ARI)
or urinary tract infection (UTI). Acute diarrhea usually resolves on its own (less than 14 days)
and will subside without specific therapy if dehydration does not occur.

 Chronic diarrhea

It is defined as a condition where the frequency of defecation or water content in the stool
increases with the duration (duration) of illness more than 14 days. Often chronic diarrhea results
from chronic conditions such as malabsorption syndrome, inflammatory bowel disease, immune
deficiency, food allergies, chronic intolerance or chronic nonspecific diarrhea, or as a result of
inadequate management of acute diarrhea.

 Intractable diarrhea

Namely stubborn diarrhea in infants which is a syndrome in infants in the first week of age and
longer than 2 weeks without the discovery of pathogenic microorganisms as the cause and is
resistant or stubborn to therapy. The most common cause is acute infectious diarrhea that is not
treated properly.

 Nonspecific chronic diarrhea

This diarrhea, also known as irritable colon in children or toddler diarrhea, is a cause of chronic
diarrhea that is often found in children aged 6 to 54 weeks. The stool in children is soft and often
accompanied by undigested food particles, and the duration of diarrhea is more than 2 weeks.
Children who suffer from chronic nonspecific diarrhea will grow normally and have no
symptoms of malnutrition, no stool and no enteric infection.

B. ETIOLOGY

Clinically the causes of diarrhea can be grouped into 6 major groups, namely:

1. Infection (caused by bacteria, viruses or parasitic infestations)

a. Bacteria
- Escherichia coli (E. coli) E. coli bacteria are often found in vegetables or fruit that
are not washed clean, raw meat, and fresh milk.
 - Salmonella enterica (Eating food contaminated with these bacteria will cause
gastroenteritis, with diarrhea as a characteristic symptom. Salmonella enterica
bacteria are found in undercooked eggs, meat, and unwashed fruit or vegetables).
- Campylobcter (Campylobacter jejuni is the subspecies that most frequently infects
humans. This bacterium is also found in raw chicken meat, unpasterurized dairy
products, and contaminated water).
- Shigella (These bacteria live in dirty water and food. This bacterial infection will
more easily occur in environments with poor sanitation and less clean lifestyles).

b. Viruses (These types of viruses include rotavirus, norwalk, cytomegalovirus, and

viral hepatitis. Rotavirus is the virus that most commonly causes diarrhea in
children.).
c. Parasitic infestations
- Giardia parasite (Usually found in gardens with ponds contaminated by rivers and
lakes, in swimming pools with high chlorine content, even in the aquarium where the
little one is watching fish).
- Cryptosporidium parasite (This type of parasite is usually found in public places,
such as public drinking taps in parks and in your little one's favorite water recreation
park. Cryptosporidium parasite often causes watery diarrhea that can last for 2 weeks
or more).

2. Malabsorption (Malabsorption includes impaired absorption of macro nutrients (protein,

fat and carbohydrates) or micro (vitamins and minerals). This absorption disturbance will
cause complaints and symptoms of diarrhea that continues to malnutrition). Allergies (In
children, common foods that cause allergies include: Nuts, Wheat, Soybeans, Eggs,
Cow's Milk).

3. Poisoning (The result of food poisoning varies depending on the substance that
contaminates the food consumed. Common symptoms include diarrhea, nausea,
vomiting, stomach cramps, and headaches.).
4. Imunodeficiency (The only known risk factor is having a family history of a primary
immune deficiency disorder that increases a person's risk of developing diarrhea).
 5. And other causes. The causes that are often found in the field or clinically are diarrhea
caused by infection and poisoning.

C. CLINICAL MANIFESTATIONS

First: The clinical manifestations observed in this study included vomiting, fever, seizures,
and dehydration status. The degree of dehydration is divided into no dehydration, moderate mild
dehydration and severe dehydration. The clinical manifestations that often accompany diarrhea
are vomiting (77.8%) and fever (77.8%). Vomiting worsens the degree of dehydration due to
diarrhea and makes it difficult to give oral rehydration, so the child needs parenteral
rehydration.4,5 Fever also increases the need for fluids, so the child tends to become dehydrated
(67.6% without dehydration compared to 79.4% dehydration mild moderate and 87.5% severe
dehydration The degree of dehydration had a weak correlation with age group (Spearman
correlation coefficient -0.149; p = 0.048) and diarrhea frequency (Spearman correlation
coefficient 0.170; p = 0.024). Babies tend to become dehydrated because their bodies are still
growing and developing. The higher the frequency of diarrhea, the more fluids the child tends to
be dehydrated. However, no such correlation was found, and there was no significant correlation
between the degree of dehydration and the volume of diarrhea, the duration of diarrhea, and
vomiting in this study.

D. SIGNS AND SYMPTOMS OF DIARRHEA

At first babies and children become whiny, restless, body temperature usually increases,
appetite is reduced or absent, then diarrhea develops. The stools are fluid and may be
accompanied by mucus or blood. The color of the stool gradually turns greenish because it is
mixed with bile. The anus and the surrounding area are blisters due to frequent defecation and
the stool becomes increasingly acidic as a result of more lactic acid, which comes from lactose,
which the intestines cannot absorb during diarrhea. Symptoms of vomiting can occur before or
after diarrhea and can be caused by an inflamed stomach or a disturbance of acid-base or
electrolyte balance. If the patient has lost a lot of fluids and electrolytes, the symptoms of
dehydration will become more visible. The body weight decreases, the skin turgor decreases, the
eyes and crown become sunken, the mucous membranes of the lips and mouth and the skin looks
dry. Based on the amount of fluid lost can be divided into mild, moderate, and severe
dehydration, while based on plasma tonicity can be divided into hypotonic, isotonic, and
hypertonic dehydration.

E. PATHOPHSIOLOGY

Basically, diarrhea occurs when there is disruption of water and electrolyte transportation in
the intestinal cavity. The basic mechanisms of pathophysiology that can cause diarrhea include:

1. Osmotic disorders

Osmotic disorders result from the presence of food or fluids that cannot be absorbed. The
food or liquid that cannot be absorbed will collect in the small intestine and will cause the
intestinal osmotic pressure to increase. This osmotic disorder results in a shift in fluids and
electrolytes into the intestinal cavity where a lot of fluid is drawn into the intestinal lumen. The
food or liquid that cannot be absorbed is pushed out through the anus and diarrhea occurs.

2. Disorders of secretion

Disorders of secretion are a result of certain stimuli (toxins) on the intestinal wall which will
cause an increase in the secretion of water and electrolytes into the intestinal cavity. This occurs
because of the stimulation of bacterial toxins that cause an active transport system, so that
mucosal cells experience irritation and changes in intestinal capacity that cause disruption in
intestinal function in water and electrolyte absorption. This process results in increased secretion
of water and electrolytes. Furthermore, it is excreted as diarrhea due to an increase in the
contents in the intestinal cavity.

3. Impaired intestinal motility

Hyperperistaltic intestinal motility disorders will result in a lack of opportunity for the
intestines to absorb food, resulting in diarrhea. Likewise, if the peristalsis decreases it will result
in the emergence of excess bacteria and will cause diarrhea as well.
 The result of diarrhea is the loss of water and electrolytes which causes extracellular fluid to
disappear quickly. So that there is an electrolyte imbalance that causes hypovolemic shock and
ends in death if not treated immediately.
 F. PATHWAY

infection psychology
food
Develops in the
intestines Toxic cannot be Anietas (D0080)
absorbed
Hypersecretion of water &
electrolytes malabsorption
Hyperperistalsis

Fill the intestines

The absorption of food
Increases osmotic pressure
in the intestine
decreases
Shift of water and
electrolytes to the intestines

Diarrhea (D0020)

Chapter frequency
Nauseous vomit

Loss of fluids & Gg skin integrity (DO129)

electrolytes
Appetite

Balance & electrolyte Metabolic acidosis

disorders
Out of breath
dehydration Nutritional deficit
Gas exchange disorders (D0019)

Risk of shock
 G. MANAGEMENT
1. Medical:
The basics of diarrhea treatment are:
a. Giving fluids: types of fluids, how to give fluids, the amount of administration.
b. Dietetics (way of feeding)
c. Drugs.
Basic diarrhea treatment:
1. Giving fluids
Give fluids to patients with diarrhea and pay attention to the degree of dehydration and general
condition.
 Giving fluids
Patients with rignan dehydration and moderate fluids are given orally in the form of fluids
containing NaCl and Na HCO3, KCl and glucose for acute diarrhea and because in children over
6 months the sodium level is 90 ml g / L. In children under 6 months of mild / moderate
dehydration, sodium levels are 50-60 mfa / L, the complete formula is often called: ORS.
 Parontenal fluid
Actually, there are several types of fluids needed according to the patient's needs, but all of them
depend on the availability of local fluids. In general, Ringer's lactate (RL) fluid is given
depending on weight / dehydration rignan, which is calculated by loss of fluids according to age
and body weight.
- No dehydration yet
Orally as many children want to drink / 1 cup per defecation.
- Mild dehydration
First 1 hour: 25 - 50 ml / kg BW orally
then: 125 ml / kg BW / day
- moderate dehydration
First 1 hour: 50 - 100 ml / kg BW orally (sonde)
then 125 ml / kg BW / day
Severe dehydration
Depends on the age and weight of the patient.
1. Dietetic treatment
For children under 1 year old and children over 1 year old with weight less than 7
kg Type of food:
-Milk (breast milk is lactose milk which contains low lactose and unsaturated
fatty acids, for example LLM, al miron).
-Half solid food (porridge) or solid food (nasitim), if the child does not want to
drink milk because it is unusual at home.
-Special milk tailored to the abnormalities found in milk without containing
moderate / not cold chain lactose / fatty acids.
2. Medicines
The principle of diarrhea treatment is to replace fluids lost through feces with /
without vomiting with fluids containing electrolytes and glucose / other carbohydrates
(sugar, starch water, rice flour as follows).
-Anti-scretory drugs
Acetosal, dose 25 mg / ch with a minimum dose of 30 mg.
Klorrpomozin, dose 0.5 - 1 mg / kg BW / day
-Spasmolytic drugs, etc. generally spasmolytic drugs such as papaverine, beladora
extract, opium loperamia are not used to treat acute diarrhea anymore, stool hardeners
such as kaolin, pectin, charcoal, tabonal, have no benefit in treating diarrhea so they are
no longer given.
-Antibiotics
Generally, antibiotics are not given if there is no clear cause if the cause is
cholera, tetracycline 25-50 mg / kg BW / day are given.
Antibiotics are also given when there are diseases such as: AOM, pharyngitis,
bronchitis / bronchopneumonia.

H. SUPPORTING INVESTIGATION
(a) Endoscopy
(1) Upper gastrointestinal endoscopy and D2 biopsy, if celiac disease or Giardia is
suspected. Performed if the patient experiences nausea and vomiting.
 (2) Flexible sigmoidoscopy, if diarrhea is associated with fresh bleeding through
the rectum.
(3) Colonoscopy and ileoscopy with biopsy, for all patients if the stool and blood
examination is normal, which aims to rule out cancer.
(b) Radiology
(1) CT colonography, if the patient is unable or unsuitable to undergo
colonoscopy
(2) Abdominal ultrasound or CT scan, if suspected of having biliary or prankeal
disease
c) Further examination
(1) Stool osmolality and volume after 48 hours of fasting will identify the
secretory and osmotic causes of diarrhea.
(2) Laxative examination in suspected patients requires fecal and serological
samples (Emmanuel, 2014).

I. FISIOLOGI ANATOMI
The digestive system of the digestive system and the automatic digestive system,
the digestive system which consists of the digestive system, namely the digestive system
starting from the mouth to the small intestine and the accessory organs consisting of the
liver, gallbladder, and pancreas.
Anatomy
1) Mouth
The mouth is a digestive tract that is lined by two cheeks formed by the businatorus
muscle. At the top is the palate that separates the nose and upper pharynx
2) Tongue
The tongue is composed of muscles covered with a mucous membrane. The tongue
occupies the oris cavity and is attached directly to the epiglottis in the pharynx.
3) Teeth
Humans are equipped with dental structures that are attached to the upper and lower jaw.
The first cells are temporary primary teeth (milk and decidual teeth) that grow through
the gums in children. Furthermore, the second set and is permanent to replace primary
teeth and begin to grow in children around the age of 6 years.
4) Esophagus (esophagus)
The esophagus is a muscular tube consisting of the cricoid cartilage to the cardia of the
stomach. The length increases after 3 years after the birth of the child.
5) Gastric
The adult stomach is found in the fetus before birth. The capacity of the stomach between
30-35 ml at birth will increase to approximately 75 ml. stomach is part of the digestive
tract that works mechanically and chemically.
6) Small intestine
The small intestine is divided into the duodenum, jejenum and ileum. The small intestine
is 300-350 cm long at birth and increases as the child ages
7) Large intestine
The large intestine is divided into the cecum, ascending colon, transverse colon, dendent
colon, and sigmoid colon. The length of the large intestine varies by approximately 180
cm.
8) Liver
The liver or often called the liver is the largest gland in the body. The liver is red-brown
in color, highly vascular and soft.
9) Pancreas
The pancreas is located transversally in the upper abdomen between the duodenum and
spleen in the retroperitonium.
10) Peritoneum
The peritoneum consists of a very thin, slippery, and moist serous membrane that lines
the peritoneal cavity and abdominal organs such as the abdominal cavity and pelvis.

Physiology
The physiology of the digestive tract consists of a series of ingestion processes (the
process of eating) and secretion of digestive juices. Digestive sap plays a role in helping
digestion or digestion of food, then the digestive products will be absorbed into the body
and applied in the form of nutrients. The process of secretion, digestion, and absorption
occurs continuously from the mouth to the rectum.
Mastication is the process of chewing or breaking large food particles by the teeth and
stirring the food before it enters other digestive organs. Then the food is moistened by the
salivary glands into a bolus. Swallowing (deglutition) is a reflex response caused by
afferent implants in the trigeminal, glossopharyngeal, and vagus nerves. Part of the
defection will be reflex and some of the others will be applied in volunteer activities.

J. COMPLICATIONS
a) Dehydration in the form of mild, moderate, severe, hypotonic, isotonic or hypertonic
b) Hypokalemia with symptoms of mecorismus, muscle hyptonia, weakness, bradycardia,
changes in electro-cardiagram
c) Energy and protein malnutrition, because apart from diarrhea and vomiting, sufferers
also experience hunger.
d) Hypovolemic stew.
e) There are seizures, especially in hypertonic dehydration
f) Hypoglycemia.
g) Lactose introlerance secondary to lactase deficiency due to damage to mucosal villi,
small intestine.
A NURSING CARE FOR CHILDREN WITH DIARRHEA DISEASES

Savina Tunnaja (P1337420520079)

Eva Fitriana
Evi Fitrianti
Satya Aji Prihutama
Meita Ratri Nugraheni
Bagas Surya Setyawan
Annisa Prajna Muthi
Wijdan Alya S. Shabrina
Tusi Wahyaning Pangesti
Febri Finandita
Hanindia Nurul Atikah
Lita Elisa
Setyaki 2
(P1337420520080)
(P1337420520081)
(P1337420520082)
(P1337420520083)
(P1337420520085)
(P1337420520086)
(P1337420520087)
(P1337420520088)
(P1337420520089)
(P1337420520090)
(P1337420520091)

POLYTECHNIC OF THE MINISTRY OF HEALTH, SEMARANG

MAGELANG NURSING PROGRAM D III

ACADEMIC YEAR 2020/2021

 NURSING CARE DATA WITH DIARRHEA CHILDREN

A. Assessment
Assessment Date:
a. Biodata
Name :
Age :
Gender :
Religion :
Tribe :
Status :
Profession :
Address :
Date of entry :
No. Register :
Dx Medical : Diarrhea
b. Medical history
Current medical history: The client said before entering, the client experienced
nausea and vomiting, liquid chapters more than 5 times a day, because the client's
condition was weak by the family and was immediately taken to the clinic. The client
had previously suffered from the same disease a year ago and was treated.
- Reason for coming: In accordance with the existing theory, where patients with diarrhea
come to the health center because they have loose bowel movements, the frequency is
more than 5 times a day, vomiting, high fever, and mucus bowel movements, the anus
and the surrounding area become blisters, decreased appetite, children become restless,
and cranky.
- The main complaint: The client came to the health service with reasons of weakness,
nausea, vomiting and discharge more than 5 times, the trigger was the client did not know
for sure, the client had taken entrostop to relieve it but there was no change. If you lose a
lot of water electrolyte and you become dehydrated, your stool becomes more liquid, you
 vomit, you lose weight, you have sunken crown, decreased skin tone and tugor, mucous
membranes and dry lips, and you have more than four bowel movements with watery
consistency.
B. Past medical history: Past medical history in the client / child is a history of
immunization in children
C. Family psychosocial history: The child who is being cared for will be a stressor (a cause
of stress that disrupts health) for the family and the child himself. If the family or parents
do not know the procedures and treatment of children when they are sick, it can cause
increased anxiety. After realizing the health of their children, they (the family) will act
lowly or feel guilty
D. family history: in the child's family / client there is no history of intestinal disease,
bacterial or viral infection, inflammation of the digestive tract causing diarrhea.
E. Nutrition History Foods that are given as for adults, portions are given 3 times a day with
additional fruit and milk. Malnutrition in children is especially vulnerable. Good food
processing methods, maintaining food hygiene and sanitation, hand washing habits.
F. Environmental Health history
Food storage at room temperature, not maintaining cleanliness and the environment in
which to live.
G. Pola Fungsional

a. Elimination Pattern.
Children who experience diarrhea will have more frequent bowel movements (defecate)
up to 4 times a day and rarely defecate (urinate).
b. Nutritional requirements (food and fluids).
Begins with nausea, vomiting and anorexia which leads to weight loss. food must contain
enough protein, enough fat, enough carbohydrates, low fiber / low residue, soft and easy
to digest forms of food so as not to stimulate digestion, and drink lots of water to avoid
dehydration
c. Activity needs.
Activity depends on the condition of the body weak and the pain due to abdominal
distension.
d. Rest and sleep patterns.
Depending on the presence of abdominal distension which will cause discomfort that
makes it difficult for the child to rest and sleep.
e. Relationship patterns and roles.
In this case, family or parents play an important role because children with diarrhea need
more attention when the child feels pain due to abdominal distension and the child will
feel afraid if left alone.

H. Physical Examination
- General impression: Looks sick, pale
- Level of Consciousness: Qualitative
- Vital Signs: Normal (orthostatic) blood pressure decreases, the pulse returns quickly
and is weak, very weak / disguised / not palpable
- Skin: Turgor returns slowly, does not immediately return to concave, dry mucous
membranes, very dry
- Head: Fontanella is slightly concave, concave
- Eyes: Sunken, very concave
- Heart: Capillary refill 2-4 seconds, more than 4 seconds, Heart rate increases, greatly
increased
- Lungs: Respiratory rate increases, increases and hyperapnea
- Genetalia: urine output olguria, anuria

I. Supporting Examination
 Stool examination
- Macroscopic and microscopic
- Ph and sugar content in feces
- Stool culture and resistance (plug rectum)
 Blood gas analysis if there are signs of acid-base balance disorders (Kusmaul's
breathing)
 Check urea and creatinine levels to determine kidney function
 Examination of electrolytes, especially levels of Na, K, Calcium and Phosphate
 H. Nursing Diagnoses
1. (Nanda: 00146) Anxiety b.d substance abuse. d / d restless, nauseous.
2. (Nanda: 00013) Diarrhea b.d excessive substance use. d / d liquid defection> 3 hours in
24 hours.
3. (Nanda: 00046) Skin integrity b.d disturbance of fluid volume. d / d acute pain, impaired
skin integrity.
4. (Nanda: 00205) Risk of shock b.d Hypovolemia.
5. (Nanda: 00030) Impaired gas exchange b.d ventilation-perfusion imbalance d / d
restlessness.
6. (Nanda: 00002) Deficit in nutrition due to insufficient dietary intake and diarrhea. Less
interest in food.

I. Intervention

Diagnosis 1 :

(Nanda: 00146) Anxiety b.d substance abuse. d / d restless, nauseous.

Objectives and outcome criteria: (NOC sixth edition, p. 267, code: 1402)

Objective: After nursing action it is expected that the patient's anxiety level will decrease. With
the result criteria:

a. Monitor anxiety intensity.

b. Reducing the causes of anxiety.

c. Respiratory control when anxious.

d. Use the medication as prescribed.

Intervention: (NIC seventh edition, p. 322, code: 5820)

a. Use a calm and reassuring approach.

Rational: To provide a sense of security to clients.

 b. Keep nursing equipment out of client's view.

Rational: To keep clients in a calm state.

c. Listen to clients.

d. Manage the use of drugs to reduce anxiety appropriately.

Rational: To assist in the healing process.

Diagnosis 2 :

(Nanda: 00013) Diarrhea b.d excessive substance use. d / d liquid defection> 3 hours in 24 hours.

Objectives and outcome criteria: (NOC sixth edition, p. 102, code: 1015)

Purpose: After nursing action it is expected that the digestive tract can digest and absorb
nutrients from food. With the result criteria:

a. CHAPTER frequency returned to normal.

b. Stool consistency increases.

c. Peristalsis increases.

d. Diarrhea decreased.

Intervention: (NOC seventh edition, p. 206, code: 0430)

a. Defecation monitors include frequency, consistency, shape, volume, and color in an

appropriate manner.

b. Monitor bowel sounds.

Rational: To find out abnormalities in the intestine.

c. Instruct the patient regarding high-fiber foods in an appropriate manner.

Rational: To increase adherence to the therapeutic program.

d. Give warm fluids after eating in the right way.

Rational: To maintain the digestive system.

Diagnosis 3 :

(Nanda: 00046) Skin integrity b.d disorders of fluid volume. d / d acute pain, impaired skin
integrity.

Objectives and outcome criteria: (NOC sixth edition, p. 123, code: 1101)

Purpose: After nursing action it is expected that the patient's skin integrity and function will not
be disturbed. With the result criteria:

a. Good skin integrity can be maintained.

b. There are no cuts / lesions on the skin.

c. Good tissue perfusion.

d. Maintain skin elasticity.

Intervention: (NIC seventh edition, p. 314, code: 3590)

a. Check the skin and mucous membranes for redness, extreme warmth, edema, or
drainage.

Rational: To ensure there is no irritation to the skin.

b. Check clothes that are too tight.

c. Document mucous membrane changes.

d. Teach family members to recognize signs of skin breakdown exactly.

Rational: For efforts to prevent skin damage.

Diagnosis 4 :

(Nanda: 00205) Risk of shock b.d Hypovolemia.

Objectives and outcome criteria: (NOC sixth edition, p. 605, code: 0414)

Purpose: After nursing action is expected the risk of shock can be controlled. With the result
criteria:

a. Systolic blood pressure within normal limits.

 b. Diastolic blood pressure within normal limits. Normal heart rhythm.

c. Normal breathing rate.

d. Not going pale

Intervention: (NIC seventh edition, p. 210, code: 4250)

a. Monitor TTV, orthostatic blood pressure, mental status, and urine output.

Rational: To determine the patient's vital status.

b. Position the patient for optimal perfusion.

c. Create and maintain airway patency as needed.

d. Give IV fluids to crystalloids and colloids as needed.

Rational: To maintain electrolyte balance.

Diagnosis 5 :

(Nanda: 00030) Impaired gas exchange b.d ventilation-perfusion imbalance d / d restlessness.

Objectives and outcome criteria: (NOC sixth edition, p. 636, code: 0402)

Purpose: After nursing action, it is expected that the gas exchange disorders in the alveoli can be
resolved. With the result criteria:

a. Normal oxygen saturation.

b. Normal balance of ventilation and perfusion.

Intervention: (NIC seventh edition, p. 72, code: 3390)

a. Maintain patent airway.

Rational: To maintain the airway.

b. Position to facilitate proper ventilation / perfusion matching.

c. Monitor breathing and oxygenation status.

Rational: To determine the development of the patient's breath.

Diagnosis 6 :

(Nanda: 00002) Deficit in nutrition due to insufficient dietary intake from diarrhea, less interest
in food.

Objectives and outcome criteria: (NOC sixth edition, p. 368, code: 1014)

Purpose: After nursing actions are expected to meet nutritional needs. With the result criteria:

a. The desire to eat / appetite increases.

b. The stimulation to eat increases.

c. Adequate nutrient intake.

Intervention: (NIC seventh edition, p. 197 Code: 1100)

a. Instruct client regarding nutritional needs.

Rational: To find out the client's nutritional deficiencies.

b. Determine the number of calories and types of nutrients needed to meet nutritional
requirements.

c. Monitor calories and food intake.

Rational: To identify imbalances in nutritional needs.

d. Monitor trends in weight gain or loss.

Rational: To assist in the identification of malnutrition.

J. Implementation
1) Diagnosis 1:
- Use a calm and reassuring approach.
- Keep nursing equipment out of view of clients
- Listening to clients.
- Manage the use of drugs to reduce anxiety appropriately.
2) Diagnosis 2:
- monitor bowel movements including frequency, consistency, shape, volume and color
in an appropriate manner.
- Monitor bowel sounds.
- Provide patient instructions regarding high-fiber foods in an appropriate manner.
- Give warm fluids after eating in an appropriate manner.
3) Diagnosis 3:
- examine the skin and mucous membranes for redness, extreme warmth, edema, or
drainage.
- Checking clothes that are too tight.
- Documenting mucous membrane changes.
- Teach family members to recognize the signs of skin damage precisely.
4) Diagnosis 4:
- Monitors TTV, orthostatic blood pressure, mental status, and urine output.
- Positioning the patient for optimal perfusion.
- Maintain patent airway as needed.
- Provide IV crystalloid and colloid fluids as needed.
5) Diagnosis 5:
- Maintain patent airway.
- Positioning to facilitate proper ventilation / perfusion matching.
- Monitor breathing and oxygenation status.
6) Diagnosis 6:
- Instruct clients regarding nutritional needs.
- Determine the number of calories and types of nutrients needed to meet nutritional
requirements.
- Monitor alori and food intake.
- Monitor trends in weight gain or loss.
K. Evaluation
Nursing evaluation is prepared using the SOAP method. Nursing evaluation is carried out
for 3 days to carry out nursing care. The results of the evaluation from diagnoses 1 to 3
are:
 (Nanda: 00146) Anxiety b.d substance abuse. d / d restless, nauseous.

Evaluation :

After the intervention, the patient was not anxious. In accordance with the outcome
criteria set at the beginning of providing this nursing care, the nursing goals were
resolved, according to the expected outcome criteria, the intervention was stopped.
 (Nanda: 00013) Diarrhea b.d excessive substance use. d / d liquid defection> 3
hours in 24 hours.
Evaluation :
The patient says he drinks 8 glasses of water (+ 200 cc) daily. Objective: Elastic skin
turgor, moist lip mucosa, Assessment: problem resolved. Planning: Intervention is
stopped.
 (Nanda: 00046) Skin integrity b.d disorders of fluid volume. d / d acute pain,
impaired skin integrity.
Evaluation :
Damage to skin integrity b.d irritation due to frequent defecation and watery stools
(Wong, 2009). The outcome criteria defined in the literature review are as follows: The
child looks comfortable (Wong, 2009). Evaluation of this case on the third day of data
obtained: The patient's mother said that her child was not crying when she cleaned the
anal area. In accordance with the outcome criteria set at the beginning of providing
nursing care, the nursing goals were resolved, according to the expected outcome criteria,
the intervention was stopped.
 (Nanda: 00205) Risk of shock b.d Hypovolemia.
Evaluation :
- The patient says that the shortness of breath is reduced O: - The swelling has begun to
decrease - There is no redness - The frequency of breath is moderate A: The problem is
partially resolved P: Continue the intervention: 4.3 Monitor fluid intake and output 4.4
Monitor vital signs 4.7 Collaboration of diuretic administration
In connection with this diagnosis, nursing interventions were arranged to be carried out
for both patients according to the needs of each patient such as monitoring dehydration
status if needed, monitoring vital signs, monitoring fluid status including fluid intake and
output, monitoring hemoglobin and hematocrit levels, monitoring body weight. and
encourage parents to increase oral intake (Nanda Nic Noc, 2016). After treatment, the
researchers obtained an evaluation that the problem of hypovolemia was partially
resolved in the pediatric patients using the planned intervention. One sign of a child
patient is still defecating with a decreased frequency of 2-3 times a day
 (Nanda: 00030) Impaired gas exchange b.d ventilation-perfusion imbalance d / d
restlessness.
Evaluation :
- The patient says he is still short of breath O: - Fast breathing rhythm - RR: 29x / minute
- There is use of breathing muscles - There is a nostril A: the problem has not been
resolved P: Continue the intervention: 1.1 Monitor the breathing pattern (frequency,
depth, breath effort ) 1.2 Monitor additional breath sounds 1.3 Monitor sputum 1.4
Position the semi-fowler or fowler 1.5 Give drink warm water 1.6 Give oxygen, if
necessary 1.7 Teach effective cough
 (Nanda: 00002) Deficit in nutrition due to insufficient dietary intake from
diarrhea, less interest in food.
Evaluation :
can be resolved after the 5th day of treatment marked with S: the patient's mother says
her child is ready to eat, the patient's mother says her child finished her food, O: when
weighing her weight: 32 kg, the skin looks moist, the skin turgor returns quickly, the lip
mucosa is moist, CRT <2 seconds, A: goals are reached, food and fluid intake does not
deviate from the normal range, oral food intake is mostly adequate, P: intervention is
stopped.
Based on facts and theories, it can be concluded that the comparison between evaluations
that appear in patients against the outcome criteria and goals set by the author, the authors
formulate the problem of nursing nutritional imbalances less than body needs in children
 with diarrhea is resolved, which is marked by the occurrence of body weight up to the
ideal range.

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NANDA, NIC, NOC 2015