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    Bahasa Inggris Kel 6

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    Akun Nyampah
    Diarrhea was assessed in a patient including their identity, medical history, physical assessment, nursing diagnoses, and care plan. The physical assessment revealed diarrhea, weakness, fever, abdominal tenderness, and electrolyte imbalances. Nursing diagnoses included excessive fluid loss putting the patient at risk for dehydration. The care plan focused on monitoring fluid intake and output, assessing vital signs, weighing the patient daily, and providing oral rehydration solutions. A second diagnosis was inadequate nutrition from malabsorption. The plan aimed to encourage eating small, frequent meals and oral hygiene. A third diagnosis was acute pain from hyperperistalsis and irritation, treated by encouraging pain reports and providing analgesics.

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    Bahasa Inggris Kel 6

    Uploaded by

    Akun Nyampah
    42 views7 pages
    Diarrhea was assessed in a patient including their identity, medical history, physical assessment, nursing diagnoses, and care plan. The physical assessment revealed diarrhea, weakness, fever, abdominal tenderness, and electrolyte imbalances. Nursing diagnoses included excessive fluid loss putting the patient at risk for dehydration. The care plan focused on monitoring fluid intake and output, assessing vital signs, weighing the patient daily, and providing oral rehydration solutions. A second diagnosis was inadequate nutrition from malabsorption. The plan aimed to encourage eating small, frequent meals and oral hygiene. A third diagnosis was acute pain from hyperperistalsis and irritation, treated by encouraging pain reports and providing analgesics.

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    bahasa Inggris kel 6

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    Diarrhea was assessed in a patient including their identity, medical history, physical assessment, nursing diagnoses, and care plan. The physical assessment revealed diarrhea, weakness, fever, abdominal tenderness, and electrolyte imbalances. Nursing diagnoses included excessive fluid loss putting the patient at risk for dehydration. The care plan focused on monitoring fluid intake and output, assessing vital signs, weighing the patient daily, and providing oral rehydration solutions. A second diagnosis was inadequate nutrition from malabsorption. The plan aimed to encourage eating small, frequent meals and oral hygiene. A third diagnosis was acute pain from hyperperistalsis and irritation, treated by encouraging pain reports and providing analgesics.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    42 views7 pages

    Bahasa Inggris Kel 6

    Uploaded by

    Akun Nyampah
    Diarrhea was assessed in a patient including their identity, medical history, physical assessment, nursing diagnoses, and care plan. The physical assessment revealed diarrhea, weakness, fever, abdominal tenderness, and electrolyte imbalances. Nursing diagnoses included excessive fluid loss putting the patient at risk for dehydration. The care plan focused on monitoring fluid intake and output, assessing vital signs, weighing the patient daily, and providing oral rehydration solutions. A second diagnosis was inadequate nutrition from malabsorption. The plan aimed to encourage eating small, frequent meals and oral hygiene. A third diagnosis was acute pain from hyperperistalsis and irritation, treated by encouraging pain reports and providing analgesics.

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    of 7

    DIARRHEA

    PATIENT ASSESMENT

    BIBLIOGRAPHY

    Campbell, cline . 1989. Nursing diagnosis Dan intervention in nursing

    practice second edition. Canada: A Wiley medical publication.

    Doenges, Marilynn E. 1989. Nursing care plans edition 3.

    United stated of America: F.A. Davis company.

    Thompson, June M. 1986. Clinical nursing 3. United states of America

    the C. V; Mosby company.


    DIARRHEA

    ASSESMENT
    A. Patient Identity
    1. Name
    2. Gender
    3. Age
    4. Work/Job
    5. Education
    6. Marietal Status
    7. Nationality
    8. Assurance
    9. Address
    10. Hospital Register Number
    11. Data of Entering
    B. Nursing Care Plans
    1. Main sigh
    Client come with defecate sigh. Defecate more than 3 times, vomit
    passion eat downhill, sometimes the body of temperature high.
    Generally feces form of dilution can mixed mucus, blood.
    2. Present disease history
    a. When the client experience of sigh
    b. What the caused of diarrhea?
    c. What had been to overcome the sigh?
    d. What the client had been decrease lust to eat, vomit and
    stomachache
    3. Last disease history
    a. What the client have suffered disease of from same previous?
    b. What the client have suffered disease that ataek gastrointestinal
    channel like dysentri or cholera?
    4. History of family disesase
    a. Do your family have a same disease like you?
    5. Phisically assesment
    a. General situation
    Weakness, fatique, malaise.
    b. Vital sign
     Temperature : 380C
     Blood pressure : 90/60 mm Hg
     Breathe : 25 x/Minutes
     Heart rate : 95 x/Minutes
    c. Eye
    Eye paint,mucous membrane pale, blurred vision.

    d. Skin
    Skin/mucous membranes : poor turgor ;dry, skin lesions may be
    present; e.g. erythematic nod sum (raised, tender, red and swollen)
    on arms, face; pyoderma gangrenousum (purulent pinpoint
    lesion/boil with a purple border) on trunk, legs, ankles.
    e. Mouth
    Cracking of tongue (dehydration/malnutrition).
    f. Abdomen
    Abdominal tenderness/distention, diminished bowel sound, absence
    of peristaltic or presence of visible peristaltic
    g. Activity/rest
    Weakness, fatigue, malaise, exhaustion, insomnia, not sleeping
    through the night because of diarrhea. Feeling rest less and
    anxious. Restriction of activities/work due to effects of disease
    process
    h. Circulation
    Tachycardia (response to fever, dehydration, inflammatory process,
    and pain). Bruising, ecchymotic areas(insufficient vitamin k).
    Bp : hypotension, including postural.
    i. Ego integrity
    Anxiety, apprehension, emotional, upsets, e g: feelings of
    helplessness/hopelessness.
    Acute/chronic stress factors , e. g , .family/job – related, expense of
    treatment.
    Cultural factor – increased prevalence in Jewish population.
    Withdrawal, narrowed focus, depression.
    j. Elimination
    Stool texture varying from soft formed to mushy or watery
    unpredictable, intermittent, frequent. Uncontrollable episodes of
    bloody diarrhea. (as many as 20 - 30 stools/d): sense of urgency/
    cramping (tenesmus); passing blood/pus/mucus with or without
    passing feces. rectal bleeding. History of renal stones(dehydration).
    Diminished bowel sounds, absence of peristaltic or presence of
    visible peristaltic hemorrhoid, anal fissures (25%); perianal fistula
    (more frequently with crohn,s) oliguria.
    k. Food/fluid
    Anorexia : nausea/vomiting
    Weight loss
    Dietary intolerance /sensitivities, e.g. , raw fruits/vegetable, dairy
    products fatty foods
    Decreased subcutaneous fat/muscle mass
    Weakness, poor muscle tone and skin turgor
    Mucous membrane pale; sore, inflamed buccle cavity.

    l. Hygiene
    Inability to maintain self-care
    Stomatisis reflecting vitamin deficiency
    Body odor
    m. Pain/comfort
    Paint/tenderness in lower – left quadrant (may be relieved with
    defecation)
    Migratory join pain, tenderness (arthritis)
    Eye pain, photophobia
    Abdominal tenderness/distention.
    n. Safety
    History of lupus erythematosus, hemolytic anemia, vasculitis
    Arthritis (worsening of symptoms with exacerbations in bowel
    disease)
    Temperature elevation 104 – 1050F(acute exacerbation)
    Blurred vision
    Allergies to food/milk products(release of histamine into bowel has
    an inflammatory effect)
    Skin lesions may be present; e.g., erythematic nod sum (raised
    tender, red and swollen) on arms, face; pyoderma gangrenous
    (purulent pinpoint lesion boil with a purple border) on trunk, legs,
    ankles.
    Ankylosing spondylitis
    Uveitis, conjunctivitis/iritis.
    o. Sexuality
    Reduced frequency/avoidance of sexual activity
    p. Social interaction
    Relationship/role problems related to condition inability to active
    socially

    NURSING DIAGNOSIS
    a. Diarrhea may be related to presence of toxins
    Actions/ Interventions Rationale
     Observe and record stool  Helps diferentiate individual
    frequency, characteristics, disease and assesses severity of
    amount, and precipitating episode.
    factors.

     Promote bedrest, provide  Rest decreases intestinal motility


    bedside commode. as well as reducting the
    metabolic rate when infection or
    hemorrhage. is complication.
    Defecation urges may occur
    without warning and be
    uncontrollable, increasing risk of
    incontinence/falls if facilities are
    not close at hand.

     Remove stoo promptly.  Reduces noxious odors to avoid


    Provideroom deodorizers. undue patient embarrassment.

     Provide opportunity to  Presence of disease with


    ventrutions related to disease unknown cause that is difficult to
    process cure and that may reguire
    surgical intervention can lead to
    stress reactions that may
    aggravate condition.

    b. Fluid volum deficit risk factors may include excessive losses through
    normal routes (severe frequent diarrhea, vomiting).

    Actions/ Interventions Rational


     Monitor 1 & 0, not number,  Provides information about
    character,and amount of stool; overall fluid balance, renal
    estimate insensible fluid losses; function, and bowel.disease
    e.g., diaphoresis. Measure urine control, as well as guidelines for
    specific gravity, observe for fluid replacement.
    oliguria

     Asses vital signs(bp, pulse,  Hypotension (including postural),


    temperature). tachycardia, fever can indicate
    response to and /or effect of fluid
    loss.

     Weigh daily  Indicator of overall fluid and


    nutritional status.

     Observe for overt bleeding and  Inadequate diet and decreased


    test stool daily for occult blood. absorption may lead to vitamin K
    deficiency and defects in
    coagulation, potentiating risk of
    hemorrhage.

     Note generalized muscle  Excessive intestinal loos may


    weakness or cardiac lead to electrolyte imbalance,
    dysrhythmias. e.g., potassium, which in
    necessary for proper skeletal and
    cardiac muscle function. Minor
    alterations in sorum levels can
    result in profound and/or life-
    threatening symptoms

    c. Nutrition, altered: less than body reguirements may be related to altered


    absorption of nutrients.

    Actions/ Intervention Rationale


     Weigh daily  Provides information about
    dietary needs/effectiveness of
    therapy

     Recommend rest before  Quiets pristalsis and increases


    meals available energy for eating

    .
     Provide oral hygiene  A clean mouth can enhance
    the taste of food.

     Encourage patient to  Hesitation to eat may be


    verbalize feelings concerning result of fear that food will
    resumption of diet cause exacerbation of
    symptoms

    d. Pain (acute) may be related to hyperperistalsis, prolonged diarrhea,


    skin/tissue irritation perirectal excoriation, fissures; fistulas.

    Actions/ Intervention Rationale


     Encourage patient to report pain  May try to tolerate pain, rather
    than request analgesics.

     Note nonverbal clues, e.g.  Body language/nonverbal clues


    restlessness, reluttance, may be both physiologic and
    abdominal guarding, withdrawel, may be used in conjunction with
    and depression. Investigate verbal es to edentity
    discrepancies between verbal extent/severity of the problem
    and nonverbal clues.

     Review factors that aggravate or  May pinpoint precipitaling or


    alleviate pain. aggravating factors (such as
    stressfull events, food
    intolerance) or identify
    developing complications.

     Observe/record abdominal  May indicate diveloping


    distention, increased temperature intestinal obstruction from
    decreased BP. inflammation, edema, and
    scarring.

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