Group 5 Nursing process Assesment Name : Mr. A Sex : Male Age : 20 th
Marital Status : Marriage Occupation : Farmer Address : Arizona Strees 6B Diagnose of Medic : Diarrhea Priority Problem : Defecation increases with increasing fluid content in feces Case History : Patient said he felt nausea, vomiting, abdominal pain and defecation increases with increasing fluid content in feces, bowel elimination 8x in days 4 days ago after he ate some spicy foods. And then, patient go to hospital to check his condition and advices hospitalization by doctors. Family Case History : - Activity Daily Living Eat dan Drink Diet before sick: ate 3x/days, often eat spicy food, eat 10 tablespoon, food components is rice, vegetables, side dish. Diet during illness: ate 2x/ days, ate only 4 tablespoon, anorexia, food components is rice, vegetables, side dish, fruit.
Drinking patterns before sick: patients drinking mineral water 8 glass/days (2lt) Drinking patterns during sick: patients drinking mineral water 4 glass/days (1lt) Elimination : Defecation before sick: frequency 1x/days, solid consistency Defecation during sick: frequency 8x/days, liquid consistency. Urinary patterns before sick: frequency 6x/days, color is clear yellow Urinary patterns during sick: frequency 2x/days, dark yellow
Rest and Sleep : He sleep at 9 p.m. every night, never getting sleep at afternoon. Personal Hygiene : He always take a bath twice at per day
Physical Assessment General Physic Compos mentis, body weakness Vital Sign Pulse rate : 110x/ minutes Temperature : 36,9 o C Respiration rate : 21x/ minutes Blood pressure : 90/70 mmHg
Chest Inspection: symmetrical chest, flat round shape, symmetrical chest wall movement, there is no retraction of accessory muscles. Palpation: No suspicious lump Percussion: resonant lung, heart dullnes Auscultation: breath rhythm irregular, vesicular breath sounds, no additional breath sounds.
Integument Assessment Decreased skin elasticity, skin turgor back in 4 seconds
Abdominal Inspection: symmetric Auscultation: Peristaltic increased 20x/mnt Palpation: skin turgor is not straight back in 1 second Percussion: Hipertimpan, flatulence Extremities: The left arm is attached infusion, both legs move freely, no edema.
Therapy 1. Infusion RL 15 TPM (750 cc): To replace lost body fluids 2. Injection Novalgin 3x1 amp 3. Injection Cefotaxime 3x1 amp (500mg/ml cefotaxime): Antibiotics. Nursing Diagnostic 1) Bodys fluid volume deficit related to excess output 2) Acute pain related to biological factors increasing intestinal motility, hiperperistaltic 3) nutrition less than body requirements related to inadequat intake