NURSING CARE DOCUMENTATION

Supporting lecturer : Mr. Ali Imron, M.Hum

Arranged by:

INDAH NUR AFIFAH

P1337420517067

Antasena 2

HEALTH POLYTECCHNIC OF SEMARANG

DEPARTEMENT OF NURSING MAGELANG

2018/2019
A. ASSESSMENT
1. Identitas Patient

Name of patient :Mrs. "S"

Gender : Female

Age : 23 Years old

Address : Magelang

Religion : Islam

Job : Entrepeneur

Ethnicity : Java

Medic Diagnosis : Gastroenteritis

2. Identity Of The Person In Charge

Name : Tn. "F"

Age : 40 years old

Occupation : Teacher

Address : Magelang

Religion : Islam

Education : Junior High School

Relationship with patient: father

3. Health History

I.Main Complaint

When MRS : Fever, diarrhea, accompanied by vomiting

At review : Clients say that the body feels weak, fever accompanied by
vomiting.

II. Disease History Now

Mother said hot body 2 days ago, CHAPTER 5x / day yellow-green mixed with
mucus, and accompanied by vomiting 2x / day, then taken to US Medical Center
SYIFA Waru Kulon Pucuk Village Lamongan.

III. Past medical history

 Mother said that once had sick Diarrhea 8x / day every 1-2 hours once yellow color,
accompanied by vomiting, hot body and do not want to eat.

IV. Family Disease History

Mother said in the family members there who perna experience diarrhea pain as in
the client's natural.

V. Social History

Mother said that living in a dusty and densely populated environment and eager to
get well and go home.

4. Physical Examination

General situation : weak clients, heat, vomiting and diarrhea

Awareness : composmentis

TTV : 80/50 mmHg Tension, 112x / mnt pulse, 390 C temperature, RR 22x
/ min

Head to toe check :

a. Head : Spherical head shape, black hair color, no bumps, clean scalp.

b. Eyes : Symmetrical, no secretions, pink conjunctiva, white sclera, cowong eyes.

c. Mouth : Dry lips mukosa, no stomatitis, clean tongue.

d. Nose : Symmetrical, no secretions, no respiratory nasal lobe, no polyp.

e. Ear : Symmetrical, no lumps, ear holes clean, no ad serumen.

f. Neck : No enlargement of the tyroid, limphe, no jugular vein dams, no stiff neck.

g. Chest. Inspection : symmetrical chest, flat round shape, symmetrical chest wall
movement, no respiratory muscle retraction.

Palpation : No suspicious lumps

Percussion : lung-parusonor, heart dullnes

Auscultation : Regular breathing rhythm, vesicular breath sounds, no additional breath

sounds.

h. Stomach. Inspection: symmetrical

Auscultation : Peristaltic increases 40x / mnt

Palpation : The skin turgor does not return directly in 1 second

Percussion : Hipertimpan, flatulence

 i. Back : No spinal abnormalities (kyfosis, lordosis, scoliosis) no motion pain.

j. Genetalia : female gender, no odem, no abnormalities, perineal skin redness

k. Anus : There is no suspicious lump, the skin of the reddish anus area.

l. Extremities : Left arm attached infusion, both legs move freely, no odem.

5. Gordon Functional Assessment

1. Perception and health maintenance

Families say health is important, if any family is sick it will soon be taken to the
nearest health service.

2. Patterns of nutrition and metabolism

Eating : Ny. "S" is not an appetite, eat only 3 spoonfuls, but before diarrhea is
willing to spend 1 serving.

Drink : Ny. "S" drink is not too much.

3. Pattern Elimination

BAK : 5x / day

CHAPTER : 5x / day yellow-green color mixed with mucus

4. Patterns of activity and practice

The patient feels weak and complains of pain

5. Sleep rest pattern

Patients often complain about difficult to sleep

6. Sensory and cognitive perception patterns

The patient is familiar with the people around him

7. Pattern relationship with others

Patients already know each other around them

8. Reproductive / sexual patterns

Clients of female sex, do not experience genetic disorders

9. Patterns of self-perception and self-concept

The client wants to recover quickly

10. Coping mechanism pattern

 If the patient is not feeling well, it will complain of pain

11. Pattern of trust / confidence

The family is all Muslim, the family is sure everything is arranged by Allah SWT.

 Serology / Immunology Checker

Checking type Check up result Normal Value

Widal Test

-O - (Negative) Negative

-H 1/80 Negative

-PA - (Negative) Negative

-PB -( Negative) Negative

Therapy:
1. Infusion RL 15 tpm (750 cc): To replace lost body fluids.
2. Novalgin Injection 3x1 amp (metampiron 500 mg / ml): Analgesic Group
3. 3x1 amps of injection of Ulsikur (200mg / 2ml symmetidine): Antacids and Ulcers
4. Injection of Cefotaxime 3x1 amp (cefotaxime 500mg / ml): Antibiotics.

DATA ANALYSIS

Patient Name : Mrs. "S" Number Room : 5

Age : 23 years old

Data Nursing problems Etiology

DS: the client has a yellowish- Disruption of fluid balance Excessive output
green turf deficit

DO: Skin turgor decreases,

mouth dry, lazy to eat

DS: Patient says that Comfort discomfort (pain) Hyperperistaltik

experiencing flatulence

DO: after percussion is known

distensi client, client seems to
hold the pain.

Peristaltic: 40x / min

Pain Scale:

P: before and after CHAPTER

Q: pain like squeezing

 R: in the epigastric region

S: pain scale 5

Q: often

DS: the client says that the Impaired pattern of Bacterial infection
client BAB many times elimination CHAPTER

DO: client looks limp, eyes

cowong.

B. NURSING DIAGNOSIS
1. Excessive fluid balance disturbance b / d output

2. Impaired sense of comfort (pain) b / d hiperperistaltik

3. Elimination elimination CHAPTER: diarrhea b / d bacterial infection

C. INTERVENTIONS
Number
Goals and KH Intervention Rational
Dx

1 After 2x24 Hours Nursing
Measures Goal: The
volume of fluids and
electrolytes in a balanced
body (lack of fluids and
electrolyte fulfilled)
With KH:
- Turgor skin quickly back.
- Eyes return to normal
1. monitor signs of lack of fluids 1. Determine the next intervention
2. observe / record the results of 2. Know the fluid balance
fluid intake output
3. Reduce fluid loss
3. encourage clients to drink a lot
4. Increase participation in care
4. Explain to the mother the signs
5. replace the fluid that comes out and
of lack of fluids
overcome diarrhea
5. give therapy according to
advice:

- Membranmukosabasah - Infusion RL 15 tpm

- balanced output intake

2 After 2x24 hours of . Thorough complaints of pain, 1. Identification of the characteristics of

nursing action with goal:
sense of comfort is
fulfilled, the client is free
from abdominal distension
with KH:
defect intensity (with a scale of 0- & associated factors is a very important
10). choose the appropriate intervention & to
evaluate the effectiveness of the therap
2. Encourage clients to avoid
allergens 2. Reduce the severity of the disease.

- The client does not grin
in pain.
- Client expressed verbal
(-)
3. Apply warm compresses to the 3. With warm compresses, abdominal
abdominal area distension will be relaxed, in case of acu
inflammation / peritonitis will cause the s
4. Collaboration of infection.
 - Wajahrileks - Give medication as indicated 4. Corticosteroids to prevent allergic rea

- Skalanyeri 0-3 - Oral, IV, & inhaled steroids 5. Analgesics to reduce pain.

- Analgesics: novalgin injection 3x1

amp (500mg / ml)

- Antacids and ulcers: 3x1 amps of

injection of ulsikur (200mg / 2ml)

3 After Conducted 2x24
Hours of Nursing Action
with Purpose: BAB
Consistency soft,
frequency 1 times per day
with KH:
- Vital signs within normal
limits (N: 120-60 x / min,
S; 36-37,50 c, RR: <40 x /
min)
- Leucocytes: 4000 -
11,000
Observing TTV
2. Explain to the cause of its age
3. Monitor leukosits everyday
4. Kajipolaeliminasikliensetiapari
5. Collaboration
- Consul nutritionist to provide the
diet as per the needs of the client.
- Antibiotics: cefotaxime 3x1 amp
(500mg / ml)
1. Active fluid loss continuously affects T
2 The expert has knowledge of the caus
wandering.
3 Useful for knowing infection healing
4 To know the consistency and frequenc
CHAPTER
5 The method of eating and calorie need
based on need.

- Calculatejenisleukosit: 1-
3 / 2-6 / 50-70 / 20-80 / 2-8

D. NURSING IMPLEMENTATION
Patient Name : Mrs. "S" Number age : 5

Age : 23 years old

Date / Number.
IMPLEMENTATION PATIENT RESPONSES
Hours Dx

TUESDAY, 10/5 17 1,2,3 - Review patient DO: Skin turgor decreases, dry mouth, matacowong,
complaints and sickness
16.00
- Observe TTV TD = 80/50 mmHg, S = 390 C, N = 112, looks weak, RR
every 8 hours 22x / min

DS: The client says it will drink that much

DO: Reduced skin turgor, dry mouth mucosa,

accompanied by vomiting.

16.15 DS: the expression of a little coexist

DO: cooperative family, and will provide plenty of drink

 1 so that clients are not dehydrated

- Determine signs
of lack of fluids

- Install infusion
16.25 RL 15 tpm DS: -

1,2 DO: Ny. "S" cooperative family

Giving
medication: DS: -
• Novalgin 1 amp DO: TD = 100/70, S = 380, N = 100x / mnt, RR = 20x /
injection min
• Ulsourur
21.00 Injection 1 amp
DS: -
1,2 • Cefotaxime 1
amp injection DO: Co-operative family

- Advise for clients

to drink a lot
DS: Clients say will eat in small portions but often.
Wednesday11/5/1 1,3
1 DO: Co-operative family
Encourage clients
06.30 DS: the patient said the drink as often as possible
to rest and do
warm compresses DO: Ny. "S" family is cooperative
on the abdominal
area

- Observing TTV

- Replace infusion
RL 15 tpm
DS: -
2,3
- Assigning clients
07.30 DO: Ny. "S" cooperative family
to clients

Giving
medication:

• Novalgin 1 amp DS : -
1,3 injection
08.50 DO : TD = 100/70, S = 370, N = 100x/mnt, RR = 22x/mnt
• Ulsourur
Injection 1 amp
 • Cefotaxime 1
amp injection
DS : klienmengatakanakanmakandalamporsikeciltapiser
ing.

Observation / DO : keluargakooperatif
1,2 catathasil intake
DS: -
11.30 fluid output

Advise eating in DO: Turgor wrinkle slightly improved, mucus mouth

moist, vomiting reduced, diarrhea is reduced.
small portions but
often.

Have the patient DS: patient says pain when injected

drink plenty of it
3,2
so as not to DO: Incoming medicine no sign of allergy
14.00 dehydrate

- Explain to your
family the signs of
disbursement DS: -
Giving DO: Leukocytes: 8600 / mm3
medication:
Calculate type ofocytes: 1-3 / 2-6 / 50-70 / 20-80 / 2-8
• Dexa 1 amp
injection

• Ulsikur Injection
1amp

 Injeksi
Cefotaxime 1 amp

1,2,3
Observing TTV
Kamis, 12/5/17
- Replace infusion
06.00 fluid + drip
Neurobion
3
Advise eating in
06.30
small portions but
often
 1,3 To preserve signs
of dehydration
08.00

08.30 2,3
Giving medicine
10.00
• Ulsourur
Injection 1 amp

• Cefotaxime 1
3 amp injection

Observasileukosit

E. NURSING EVALUATION
Number.
Day /Date Development Notes
Dx

1. Tuesday S: Kien says that still feel weak

10/5/2017
O: - The client still looks limp

- Client activity is still assisted by his family

A: The problem is not resolved

P: Intervention 1-4 continues

2. S: The client says that his stomach is still sick

O: - Kien looks grinning silliness

- Client continues to hold his stomach

- Scale of pain 3

A: The problem is not resolved

P: Interventions 1,3,4,5 and 6 resumed

3. S: clients say that the BAB client many times, has begun to decrease
2x / day, still feel nauseated but not to vomit.

O: - client CHAPTER 2x / day

- Turgor skin returns <1 sec

- Eyes are not cowong

- Clients feel nauseated so do not spend the portion of food

- Client does not vomit

A: The problem of CHD elimination disorder is partially resolved

P: Maintain intervention 1-4 continue

- Assess intact fluid output every 8 hours

- Monitor for signs of dehydration

1. Wednesday S: The client says that feeling healthier

11/5/2017
O: - Clients look healthier

- Client more independent in doing its activity

 - Turgor skin <1 second back

- Eyes are not cowong

- The mouth mucosa is not dry

A: The issue is resolved

P: Intervention stopped

2. S: Kien says that her stomach pain is slightly reduced

O: Clients grinning with pain, pain scale 2

A: Part of the problem

P: Intervention resumed

3.

S: Client says that BAB already soft 1-2 / harimual have decreased,
not vomiting again.

O: - Client CHAPTER 1-2x / day, consistency slightly soft

- Client finished his food

- Client does not vomit

- Turgor skin back <1 sec

- Eyes are not cowong

- The mouth mucosa is not dry

- Client drinks 1000cc / day

A: Problems are resolved in part

P: Intervention 1-4 continues

1. Thursday12/5/201 S: The client says that his stomach is not sick

O: - Pain scales 0

- The client does not grin in pain

A: The issue is resolved

P: Intervention stopped

S: The client says that is not feeling nausea and vomiting, consistency
 CHAPTER soft.

O: - BAB Client with soft consistency

- The client does not feel nausea and vomiting

- The client spends a portion of his meal and drinks approximately

1500cc / day- Jumlahleukosit normal

A: The issue is resolved

2.
P: Intervention stopped