Action Analysis

Nursing Clinical Practice

GROUP 5
1. VERINA HERLIYANTI
2. TRIONO
3. RADIS
4. JONO SETIAWAN
1. Patient Identity
Patient name : Mrs. T
Age : 32 years old
Work : housewife
Education : High school education
Religion : Islam
Address : Hanif Fais 902 East Kusumanegara St.
Bantul
Date of entry : 14th Novemver 2018
Date of review : 15th November 2018
Medical diagnosis : GEA

2. Subjective Data
The patient said defecation more than 4x a day and naused,
vomiting
3. Objective Data
The patient looks weak, pale
Vital sign :
Blood pressure : 80/50 mmHg
Temperature : 39C
Respiration : 3ox/m
Pulse : 112x/m
a. Problem : Lack of fluid volume
b. Etiology : Diarrhea
c. Nursing Diagnosis: Lack of fluid volume associated with Diarrhea

4. Action
Health education about meeting the body's fluid needs

5. Purpose of action
So that the volume of fluid and electrolytes in the body is balanced
6. Nursing action
1.Monitor signs of lack of fluids
R: Determine the next intervention
2. Observe / record the results of the fluid output intake
R:Knowing the fluid balance
3. Encourage clients to drink a lot
R: Reducing fluid loss
4. Explain to the mother the sign of lack of fluids
R: Increase participation in care
5. Give therapy according to advice: - infusion of RL 15
tpm
R: Replace fluids that come out and overcome diarrhea

7. Collaborative action
infusion of RL 15 tpm
8. Action evaluation

S: Kien said that she still felt weak

O: - Clients still look weak
- Client activities are still assisted by his family
Vital sign:
Blood pressure: 100/90 mmHg
respiration : 29x/m
Temperature : 38C
Pulse : 80x/m
A: The problem has not been resolved
P: Interventions continue
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