DIARRHEA NURSING DOCUMENTATION

Untuk memenuhi tugas mata kuliah Bahasa Inggris

Disusun Oleh :

Andi Listiani (A12019013)

Tingkat 1A

Semester II

PROGRAM STUDI KEPERAWATAN PROGRAM SARJANA

SEKOLAH TINGGI ILMU KESEHATAN MUHAMMADIYAH GOMBONG
TAHUN AJARAN 2020
 Diarhea Assesment

Assesment :

1. Client identity
Name : Ny. M
Gender : Female
Age : 63 years old
Religion : Islam
Blood Type :A
Address : Karya Mulya, 02/08, Kebumen
Date of Review : April 23,2020
Medical Diagnosis : Diarhea
2. Responsible Identity
Name : Tn. A
Gender : Male
Age : 70 years old
Religion : Islam
Address : Karya Mulya, 02/08, Kebumen
Job : Farmer
Relationships with Clients : Husband

Main Complain :
Client say shart 5x/day

Current Medical History :

On april 18,2020 the client came to the hospital with his family, the client said he felt
hot, limp, and fluhsed. On April 18, 2020 at 08.00 am a full work-up of April 23,
2020.

First Riawverse Health :

The client’s family says they’ve never experrienced any pain right now

Family Health History :

No one has the infectious disease and the current client’s illness.
 General Condition :
Level of Consciousness : Composmentis
Eye ooen spontaneously : 5
Verbal : 4
Motor : 6

Vital Sign :
Temperature : 37,5
Pulse : 90/minute
RR : 30x/minute
TD : 130/90 mmHg
The General Appearance : The client is tired
Physical Examination :
1. Head : symetrical, gray-haired
2. Eye : symetrical, concave, not blister,good eyesight function
3. Nose : symetrical, no lessions, no red mucossa, good sense of smell is indicatd by
being able to distinguish between cooking and balm
4. Mouth : Symetrical, red lips, and moist mucosa
5. Ear : symetrical, no bumps, well marked hearing function by responding to a
nurse’s question
6. Neck : symetrical, no bump, no KGB zoom
7. Chest : not stank, sonor lunga, vesikuler, there’s no ronchi sounds, normal heart
sounds, no noise
8. Abdomen : symetrical, no lessions,hepar was intangible
 Upper external : no complaints
 Lower external : no complaints
 Integer : white warba, good skin
1. The Concept of Self
a. Body Image
The power of the client says he loves his family
b. Idealized
Family clients say they have a desire to get well
 c. Self-roles
During hospitalization, the family said are uncomfortable
d. Identity while under investigation
The client cana answer a nurse’s question
2. Feelings
The client looks weak, anxious, and frightened as the nurse examines
3. Defense Mechanism
Each client feels the client’s pain break

Social, Psyhco, an Spiritual Aspects

1. Social Aspect :
a. Social relations : clients say that the next person they meet is her husband
b. Review Interaction : client cooperative
2. Spiritual Aspect :
a. The value of Confidence : The client says the illness she suffers is trial and the
potential lack of family members in dieting
b. Worship : prayer during illness

No Kind of Activity In good health When sick

1. Nutrition 10x 24 hour 5x 24 hour
Frequency ASI, milk ASI, milk
The kind of food
The diet
2. Drink ASI, milk ASI, milk
Beverage type Susu 3 bottle/day Susu 2 bottle/day
Number of difficulties -
3. Eliminitation 1x/day 4x/day
Faal elimination Yellow yellow
Frequency Soft liquid
Color
Consistency
4. Personal hygiene 3x/day 3x/day
 Take a bath 3x/day 1x/day
Oral hygiene - -
Washed hair - -
Trim nails 3x/day 4x/day
Changes clothes
5. Rest/sleep 17.00 WIB Often
Sleep time - Abnormal
Get up at night Normal Fluid discharge
Sleep quality -
Sleep disorder

I. Support Examination
1. Diagnostic Examination
a. Blood test :
HB : 9,5 g/dl
Leukocytes : 10,300/mdl
Platelets : 38,6000/ml
Lymphocytes : 32 %
Monosit : 0%
Haemotokrit : 28,3

Focus Data Possible Causes Nursing problems

DS : Bacteria entry into the Fluid balance disorder
Family says clients intestines causes intestinal and electrolytes
shart 5x/day iritation, causing intestinal
DO : agillation to increase , food
Liquid feses filtering is difficult fluids and
consistency electrolytes to be wasted
Poor skin concistency through the feses
Sunburn eyes
DS : An inlet og bacteria in the Nutrient suuply disorder
The family said the intestinal, bowel function
client could hardly eat interuppted, is host to
 and his body would intestinak shield talk, food
suffocate saries are being wasted
DO : becausee time transt
The client looked weak, absorbtion is reduced.
vomting, intestinal Essence of food is being
noise wasted through feses, thus
causing nutrition to be
compromiised

Nurse Diagnosis :

Fluid and electrolityte balance b.d dehydration and diarhea

Nutrient need disorder, less than the body needs

No. Nurse diagnosis Destination Intervention Rasional

1. DS : Destination : Observing vital For general
Family says clients Fluid and signs conditions
shart 5x/day electrolyte Alit giving 3/day For signs of
DO : balance are Advocates a lot of dehidration
Liquid feses manitained within drinking For fluid
consistency normal limits transfe
Poor skin concistency Tupen : For secretion
Sunburn eyes Sharking can be reduced
reduced in time of
1x24 hour
The consistency
of soft feses
Good skin
DS : Improved Breast-feedling To satisfy
The family said the nutritional needs Milking nutriens
client could hardly eat in normal Observation vital To energize
and his body would Nutritional needs signs client
suffocate satisfied in 4 days To know the
DO : public
The client looked weak, condition
vomting, intestinal
noise