NURSING CARE

BASIC HUMAN NEEDS

False Elimination : Diarrhea

On Patient Baby N at Rose Ward

POLTEKKES KEMENKES SEMARANG

DIII NURSE of MAGELANG

2017/2018
 BAB II

CASE REVIEW

Date of entry :July, 20 2018

Date of assessment : July, 21 2018

Ward : Rose

No. Regristration : 00355603

Medical diagnosis : Vomitus

A. Assessment
1. Client Identifity
Name :N
Age : 15 months
Gender : Female
Occupation :-
Address : Gajuran, Gelapansari, Temanggung
Religion : Muslim
2. Person in Charge
Name : Tn. T
Age :-
Gender : Male
Occupation :-
Address :Gajuran, Gelapansari, Temanggung
Religion :-
3. History of Nursing
a. Main Complaint
Diarrhea
b. History of Nursing Now
Cough 3 days, vomiting started today has been 5 times.
c. Formerly Nursing History
 Fever, cough,flu
d. Family Health History
-
B. Assessment of Functional Patterns
1. Perceptoin of Health
Every time the client is sick, client simply rest and eat regularly.
2. Patterns of Activity and practice
Client activity on the bed, picked up by his mother, walking still weak.
3. Patterns of rest and sleep
Before getting sick : sleep 2x a day, approximately 10 hours/day.
After illness : Client have trouble sleeping, often wake up
because diarrhea, often fussy, can sleep about 15 minutes.
4. Nutrition Patterns
Before getting sick : Eating 3x a day, drink milk (ASI)
After illness : hard to eat, just drink milk (ASI)
5. Pattern of Elimination
Urination
Before getting sick :-
After illness :Yellow cloudy urination, the urinate low
when defecate.
Defecate
Before getting sick : Bowel movement once a day the morning,
dregs shape.
After illness : bowel movement 5 times, liquid
6. Cognitive Patterns
Mental status : conscious
Speak : talk is rather smooth
Vision : Normal
Hearing : Normal
7. Patterns of Self-concept
Clients show rejection of nursing care, can accept with his mother’s
persuasion, the family is very concerned about clients.
 8. Role patterns and relationships
Client lives with his mother and grandmother, second child of two
siblings.
9. Patterns of Sexuality
Client of the female sex.
10. Coping Patterns and Stress Tolerance
Support from mother to heal very strong
11. Pattern system and trush
Muslim
C. Physical Examination
1. General circumstantences : Client seems weak
2. Level of consciousness : Compos mentis (CM)
3. TTV TD :-
N : 105/minutes
T : 37celcius
RR : 44/minutes
4. Head : Clean, no lesions, smooth curly red hair, crowned
crooked head.
5. Eye : Concave, red conjunctiva, white sclera.
6. Nose : There is mucus, no lesions.
7. Mouth : Moist lips mucosa, teeth grow 5, no stomatitis.
8. Neck : No enlarged thyroid gland, no lesions.
9. Ear : There is dirt, no abrasions.
10. Skin : Smooth skin, turgor skin cack in 2 seconds.
11. Lungs I : Chest symmetrical, no edema and lesions.
Pal : Vocals fremitus same
Per : Sonor
A : Vesicular
12. Heart I : Ictus cordis not visible
Pal : Ictus cordis palpable
Per : Faint
A : S1 and S2 regular
 13. Abdomen I : Sunken
Pal : No mass, no tenderness
Per : Hypertympani
A : Intestinal bowel 42 times
14. Genitalia : Clear, no lesions, theanal part is rather red.
15. Extremities : The upper left extremity is attached to the infusion
in the radial vein.

D. Supporting Data
Examination Result Unit Unit Value
Hematology
CBC
Leukocytes 11,67 3,98-10,04
Erythrocytes 14,90 3,6-5,2
Hemoglobin 12,1 10,8-12,8
Hematocrit 37,7 35-43
MCV 76,9 73-101
MCH 24,7 23-31
MCHC 32,1 26-34
Thrombos 419 229-553

LED
1 hour <20
2 hour <20

Date : July, 22 2012

Examination Result Unit Unit Value
Feces
Regular feces
 Macroscopic
Color Yellow
Consistency liquid
Microscopic
CysteHistolitica Negative Negative
Amoeba Negative Negative
Leukocytes 00-1 Negative
Erythrocytes Negative Negative
Epithel 3-4 1-4
Ova Negative Negative

E. Data Analysis
Date/Time Data Cause Problem
July, 22 2012 SD : Defecate 5 times Infection Fecal
OD : Liquid bowel process elimination
movements, bowel sounds disorder
42 times/minute, Result :
Leukocytes 0,0-1
July, 22 2012 SD : Clients only drink milk Loss Lack of
(ASI) secondary fluid
OD : Client seems weak, to diarrhea volume
crowned crooked head

F. List of Problems
No Nursing Diagnoses Date Date Paraf
( p corresponds to E) found resolved
1. Fecal elimination disorder : July, 22 -
diarrhea is associated with 2012
changes in the digestive
process
 2. Lack of fluid volume July, 22 -
associated with secondary 2012
loss due to diarrhea

G. Nursing Plan
Date/ NO Objectives and yield criteria Interferensi Rational Paraf
Time DK
July, 1 Elimination of effective - Identification - Know the
22 defecation, after 2 x 24 hour causes of factor that
2012 nursing action with the diarrhea (drug, cause.
outcome criteria : food, bacteria, - Help
- Shaped feces, bowel etc.) identify the
movement 1-3 times. - Monitor fecal cause.
- Bowel sounds within expenditure - Strengrhen
normal limits (5-35 (frequency, the causal
times/ minute) consistency, factors.
- Good hydration form, color) - Intestinal
status : moist - Take fecal peristaltic
mucous membranes, specimens for generally
no increase in laboratoryum increases in
temperature, good examination. diarrhea.
skin turgor, urine - Intestinal - Client and
bowels within peristaltic families
normal limits. monitor. understand
- Teach clients diarrhea
and families problems.
about the causes - To improve
of diarrhea, how bowel
to cope, use of peristalsis.
diarrhea - Reduce
medications,as diarrhea
well as the and keep
 recommended nutritious.
diet.
- Grant the diet
gradually
according to the
program.
- Collaboration
providing
medice and
food with a
team of medical
nutritionists.

H. Nursing Note
Date/ Time NO DK Implementation Response Paraf
July, 22 1 Identify causes of diarrhea Laboratory examination needs
2012 to be done, Feces examination.

08.00
08.30 Monitor the expenditure of Defecation 7 times,liquid feces
feces slightly dregs.
08.30 Monitor bowel peristalsis Peristaltic intestine 40
time/minute
10.00 Take a stool specimen to Leukocyte examination 0,0 - 1
check laboratory
10.30 Provide a rough pureed diet Depleted ¼ portion of the
hospital

Provide injectable or non Join receive injection or non

injection therapy injection therapy (drug entry)
 - Ricef injection 3x3000
mg
- L-Bio
- Zinkid
July, 23 1 Monitor the expenditure of Defecation 4 times, liquid
2012 feces feces, dregs.
08.30
08.45 Monitor bowel peristalsis Peristaltic intestine 37
time/minute
11.45 Giving the SUN porridge diet Depleted 5 tablespoons

Provide injectable or non Join receive injection or non

injection therapy injection therapy (drug entry)
- Ricef injection 3x3000
mg
- L-Bio
- Zinkid

July, 24 1 Monitor the expenditure of Defecation 2 times, liquid

2012 feces feces, dregs.

I. Progress Notes
Date/ Time NO DK Progress Notes (SOAP) Paraf
July, 22 2012 1 S :- The Client’s mother said, the client is still diarrhea 7 times,
liquid feces slightly dregs.
- Eat porridge roughly depleted ¼ portion of the hospital.
O :Peristaltic intestine 40 times/ minute. Leukocytes 0,0 - 1
A : Diarrhea has not been revolved
P : Continued intervention (2,3,4,5)
July, 23 2012 1 S : The client’s mother said the client is still in the area 4 times,
liquid feces pulp. Eat SUN porridge out 5 tablespoons = 1 small
 bowl.
O : Intestinal peristalsis 37 times/minute.
A : Diarrhea has not been resolved.
P : Continued intervention (2,3,4,5)
July, 24 2012 1 S : The client’s mother told the client to defecate twice, liquid
feces, dregs a lot.
O : Liquid feces, dregs a lot.
A : Diarrhea is partially resolved.
P : Continued intervention (2,3,4,5)