C.

Nursing diagnoses
Nursing Goals and Outcome
N Intervention (NIC)
o diagnoses Criteria
(NOC)
1 Diarrhea related After nursing actions 3x24 NI
Cs :
to the process of hours, it is expected that
infection, diarrhea in the patient will - Diarhae Management
inflammation in be resolved. - Evaluation of
the intestine gastrointestinal side
NO
Subjective data: C: effects of
- Mother medication
- Bowel elimination
- Teach the patient to
kline say his
use antidiarrheal
son
drugs

CHAPTER - Evaluation of

since 5 days incoming food intake

ago
 - Mother - Electrolyte and acid - Identify the
base
kline say his causative factors
balance
son of diarrhea
CHAPTER
Result criteria:
watery 3 - Monitor signs and
a day - Shaped stool, BAB symptoms of diarrhea
Objective data: - Protect the area around - Monitor skin turgor
rectal from irritation regularly
- paxname
- Not experiencing - Measure
CHAPTER diarrhea
diarrhea/CHAPT
dilute 3 - Explain reason
ER output
- Peristalsis 24 diarrhea and rational
- Call the doctor if
minute action
- Maintain turgor there is an increase in
Child
skin bowel sounds
looks
- Monitor safe food
weak and weak
preparation

2 Impaired skin After nursing actions NI

Cs :
integrity related 3x24 hours, it is hoped
to that the patient will not - Pressure management
excretion/freque have an infection - Instruct the patient
nt defecation to wear loose
NO
C: clothing
Subjective data
- Keep skin clean to
- Tissue Integrity :
- Mother keep it clean and
Skin and mucous
patient say dry
membranes
redness of the - Monitor skin for
- Hemodyalis
butt area redness.
access Outcome
Objective data
Criteria:
- The anal
- Good skin integrity
area
can be maintained
looks red
(sensation, elasticity,
temperature,
hydration,
pigmentation)
- No wounds/lesions on - Apply lotion or
the skin oil/baby oil on the
- Good tissue perfusion reddened area

- Monitor the
- Demonstrate nutritional status of
understanding in the the patient
skin repair process and
prevent repeated injury - Bathing the
- Able to protect the patient with
skin and maintain skin warm water
moisture and natural
care.
 D. Nursing Implementation and Evaluation

Nursing Action
Patient's name : An. C
Name Student : Esmi Sinaga
NIM 14401 2017 000191
Inpatient Room : Public health center
Puuwatu No. Registration :
Date/Time D Implementation Evalu
x ation
Monda 1 1. Advise the client's Monday 25/June/2018
y mother to give anti-
25/June/20 diarrhea medicine S:
18 to the client - The client's mother said her
09:00 child had watery chapters ± 3x a
day
2. Monitor skin turgor - The client's mother said there
2
was still redness in the anal area
09.15
O:

3. Instruct the client's - Shaped faeces, CHAPTER once

2 mother to change a day three times
loose clothes on the - The client can't take medicine
11.00
client - Unable to maintain skin
o'clock
turgor
- The family has not been able to
2 4. Monitor skin for maintain the client's skin
redness moisture
- Looks red in the anus
- Giving L. Bio 1 tab/oral, Zink
11:15 5. Administration of 1 tab/oral
1 infusion A:
medication
- Diarrhea (moderate)
- Impaired skin integrity

12.30 P : Interventions 1,2,3,4 and 5 are

continued
 Tuesda 1 1. Advise the client's Tuesday 26/June/2018
y mother to give anti- S:
26/June/20 diarrhea medicine - The client's mother said her
18 to the client child was watery
- The client's mother said there
09:00
was still redness in the anal area
O:
2 2. Monitor skin turgor
- Shaped faeces, CHAPTER
twice a day
09.30 - Able to maintain skin turgor
3. Instruct the client's - The family is starting to be able
2 mother to change to maintain the client's skin
loose clothes on the moisture
client - Looks red in the anus
09.45
- Giving L. Bio 1 tab/oral, Zink
1 tab/oral

2 4. Monitor skin for A:

redness
- Diarrhea (moderate)
- Impaired skin integrity
11.00
o'clock 5. Administration of
1 infusion P : Interventions 1,2,3,4, and 5 are
medication maintained

12.00
6. Applying lotion or
2 baby oil to the area
anus
12.30
Wednesda 1 1. Advise the client's Wednesday 27/June/2018
y mother to give anti-
27/June/2 diarrhea medicine S:
018 to the client - The client's mother said her
09:00 child had a bowel
movement once a day
2 - The client's mother said the
2. Monitor skin turgor area around the anus was no
longer red
09.30 O:
- CHAPTER frequency once a day
09.45 2 3. Instruct the client's with a solid consistency
mother to change - The client's skin turgor is
loose clothes on the dry
client - The family is able to protect the
skin and maintain skin moisture
- The skin around the client's
4. Monitor skin for anus doesn't look red anymore
O'clock. 2 - Giving L. Bio 1 tab/oral, Zink
redness
11.00
1 tab/oral

1 5. Administration of
12.00 A: Diarrhea is resolved, good skin
infusion
integrity is maintained
medication

P: Intervention is maintained