Name : Wahdini

Nim : 2014401110029
Subject : Nursing English II
Supporting Lecturer : Dewi Setya
Paramitha Ns.,M.Kep
NUM DATE ETIOLOGY PROBLEM

1 Subjective Date : Dhydartion Hyperthermia

• mother client said that his child is fever

Objective Date :
• clients are very bright but of hospital admissionsilent client and looks very weak.
• the client looks weak, pale face, lips look dry. clients just lay in the bed and
sometimes carried away by her by her mother. body temperature on the client of 38.9
celcius degree.
• the client’s general condition was very weak, the face looked pale. His consciousness
level was compos mentis with total score of Glasgow Coma Scale was 15 E4V5M6.
The result of vital signs measurement were temperature , respiration rate
breathe/minute and heart rate 98 beats/minute.
• when the plapable is warm with the temperature is 38,9 C
• Rate was 32 breathe / minute , Shallow and Regular
NUM DATE ETIOLOGY PROBLEM

2 Subjective Data: Active fluid volume loss Deficient fluid volume

• Client father said during in hospital client still frequent bowel but not as often
as before entrance of hospita and clien still looked weakness.
• mother client said that his child is fever
• Objective Data:
• His consciousness level was compos mentis with total score of Glasgow Coma
Scale was 15 E4V5M6.
• The result of vital signs measurement were temperature 38,9 , respiration rate
32 breathe/minute and heart rate 98 beats/minute.
• clients are very bright but of hospital admissionsilent client and looks very
weak.
• Balance on hypertermi= - 332,12 cc /24 hours
• Fluid balance = + 87,88
• IWL on hypertermi = 633,12 cc
• the skin feels dry and rough.
• when the plapable is warm with the temperature is 38,9 C
• Lips mucous membrane was dry and pale.
• Tongue looked pale and white
Num Data Etiology Problem
1. Subjective Data: Intake inadequat Imbalanced nutrition:
• The mother said that when doing assesmant on wednesday, 11th of mei less thsn body
2016 her child is defecate aproximately 4 times a day and slimy liquid. requirement
• His father said that his son did not have any allergies to food, but his child
have aellergy Milk.
• The client F was born with his birth weight was 2700 grams and birth
length was 50 cm. On the client 1 st mounth weight client is 3700 grams.
The client had rapid weight gain when he was one month until one year.
but when at this hospital client lose weight to 7000 grams client's mother
said his chiled weight 9000 grams. .
• client's mother said her son was 4 times but concentrations have started
solid, clients rarely drink and do not want to eat, just able spend 3
tablespoons porridge which is served, mother client said that his child is
fever , the client looks weak, pale face, lips look dry.
• client's mother said a week before entering the hospital, her child is
defecated frequent bowel liquid, approximately 10 times defecate liquid,
but since Sunday, two days before entering the hospital clients
increasingly frequent bowel and there is little blood and mucus. Defecate
approximately 4 times the concentration of the liquid, and there was vomit
clients limp and pale eyes sunken too sweaty.
• Mother’s clients said that client also rarely drank and did not want to eat.
Objectice Data:

• Weight for age= - 2,32 malnutrition

• Weight for stature = - 3,44 ( very thin )
• Stature for age= - 0,11 (normal)
• They child has hospitalized in Ulin General Hospital since May
• 09th 2016 with medical diagnosis Gastroenteritis
• Nutritional status : BW is 7,4 kg, BH is 78 cm, IBW is 10,8, Age is 14 mounth
• the client’s general condition was very weak, the face looked pale.
• There is thrush in the tongoe of the client. Lips mucous membrane was dry and
pale.not perfect dentition. Tongue looked pale and white
• in of hospital, decreased appetite client he would not eat. food that is given
hospital-not edible. it can be pureed strain 3 x 100 ml but just able to spend 3
tablespoons of the portion that is given. clients are also given milk pregestimil 8 x
80 cc, but also can not be spent by the client. client looks refused when given her
meal. client looked crying when given meal. Client drunk and eat use pipet.
Num Data Etiology Problem

1. Subjective Data: External Factor (moisture, defecation Impaired skin integrity

• His Mother said that patient never develop chicken pox, mumps, rubella or another frequency is increase)
disease like infectious or degenerative disease
• the client's mother said that the skin around the groin red.

• Objective Data:
• when the plapable is warm with the temperature is 38,9 C
• the skin feels dry and rough
• he buttocks and the client looke there is irittion.
• skin condition around the genital client moist, red, because of frequent bowel
movements and urination, clients using diapers
• no trauma. edeme and bleeding. There is no abnormality on the abdoment of the client.
• There was no inflammation on genitalia and the client did not develop hemorrhoid.
 Problem Priority Nursing Diagnosis:

1. Deficient fluid volume related to active fluid volume loss

2. Hyperthermia related to Dehydration (active fluvolume loss)
3. Imbalanced nutrition: less thsn body requirement related to Intake inadequate
4. Impaired skin integrity related to External Factor (moisture, defecation frequency is increase)
Thank You