Nursing in An.

A with acute diarrhea Dehydration Moderate Light (DADRS) in the

Roses Kraton Hospital Panti Nirmala
ASSESSMENT
1) Date of Assessment
The assessment was done on January 9, 2016 at 09:00 pm by conducting interviews
and observation clients and families.

2) Identity Responsible Identity

Identification of Patients Name : Mr. H
Name: An. A Age : 30 years old
Age: 5 months Male : Gender
Female :gender Education : School of mechanical engineering
Of Religion :Islam Adress : Bumi Ayu
Occupation: Private Relationships with patients: biological
parents

3) Main Complaint
An. A consistency aqueous /diarrhea> 4x a day

4) Disease History Now

2 days before admission (date January 8, 2016) clients diarrhea> 10x / hr @ 6-8
tablespoons of dregs, sprayers, no blood or slime and stench of yellow. Child
diarrhea after being given an orange, then taken to a midwife. But the child is still
having diarrhea and even throw up at any fed and watered (vomit according to what
is eaten and drunk). Therefore,the child is taken to a pediatrician, five hours before
admission vomiting (-), diarrhea (+)> 5x and urinate a lot, every half hour, then was
taken to hospital and treated.

5) Disease History Past

a. prenatal
Ny. R said An. A is first child. During the pregnancy mother an antenatal check at
health centers more than 5x and get injections of TT 2x for pregnant mothers do not
create significant interference, only vomiting were reasonable on the day of the first 3
months mother never consumed drugs or herbal banquet is not recommended, the
mother only drugs provided by the center midwife in the form of capsules and vitamin
Bc SF.Mother ever experienced abortion, and before have never used contraception.

b. Intranatal
Mothers birth to her son in health centers Inpatient an antenatal check at a
gestational age of 40 weeks, helped by the kind of spontaneous labor health center
field.
c. Posnatal
An birth weight. A 2800 gram weight and length of 47 cm, the baby started to cry
strong and bluish. Mom says do not know Apgar score at birth and no congenital
abnormality.

d. Allergy
An. A has never experienced a food allergy or medications.

e. Growth and development

At the age of 2 months, the child BB PB 4300 grams and 55 cm, can observe his
own hand, spontaneous smiles and babbling voice. At the age of 5 months, children
are able trying to reach a toy, achieve objects and observing, imitating sounds kat-
kat and turned toward the sound, as well as be able to reverse and rise head upright.

f. immunization history
At the age of 0 months to get BCG and HB-1, ages 2 months to get HB-2 + DPT +
Polio I, ages 4 months to get DPT and polio.

6) According Gondan's Functional Patterns

a. Patterns of Health Perception
According to the family, health is an important aspect in life. If there is one a sick
family member, is mainly child, others also felt the pain his parents first.

b. Nutrition patterns
Diet is fed by the awarding LLM 8 x 60 cc and 3 x servings of porridge tempe but
the mother is still breastfeeding. Suction power when child drink milk well with a dot
(for milk LLM) and the milk is there, but not often and less (60 cc milk LLM not all
gone, only 30 cc are swallowed).

c. Elimination pattern
An. A. defecation 6-7 hook, yellow, watery consistency, BAK 1 x each 2 hours,
clear yellow color.

d. Activity patterns
An. A looks less active, looked limply, but when crying loud and often fussy, all
activities child assisted by parents.

e. Rest of Sleep Pattern

Before the pain, An. A no lunch for 3 hours / day and night sleep 10 hours / day.
During An ill. A good sleep after taking medicine, afternoon nap 1 hour and 5
hours of sleep a night, as would lie awake from sleep.
f. Perception Cognitive Pattern
The mother said her son is sick with diarrhea, the mother know the details of the
understanding of the causes death and prevention of pediatricians, since mother
further more consultation about health of her son condition.

g. Relationship Pattern
From since birth, An. A always taken care of at all times by his mother, so that their
relationship is very close. Especially when sick like this, An. A not willing to leave any
moment. If it does not looked her mother, An. A directly crying.

h. Pattern Value Trust

The family converted to Islam and have always seeks to do His commandments.

7) Family Health History

a. genogram

Keterangan :

: laki-laki

: perempuan

: klien

: tinggal serumah

b. Family Disease History

No history of hypertension, asthma, diabetes and heart disease in the family.

Common diseases among family members are fever, cough, runny nose (which
instantly cured when diobat especially during transition seasons).

c. custom

Family went to the health center or a physician if any a sick family member.

8) Physical Examination

a. examination Anthropometry

BB: 5300 gr Body Length: 65 cm Arm circumference: 37 cm Bust: 32 cm

head circumference: 32 cm

b. Examination of nutritional status based on Z-score

WAZ = = = -2 (normal) HAZ = = -0.3 (normal) WHZ = = -2.5 (skinny)

c. General Situation :Conscious, less active

d. Vital signs:

High blood pressure = 130 x / min Temperature = 37 C

Respiration = 30 x / min N = content / voltage enough

e. Head

Mesorhapal shape, scalp clean, rarely hair, concave fontanel, no lumps.

f. Eye

Looks concave, sclera no jaundice, konjungiva anemic

g. Nose

Seemed no snot, no breathing nostrils.

h. Ear

Symmetrical, there are no signs of inflammation (redness (-), edema (-), discharge (-
), hearing loss (-), no secretions.,

i. Mouth

No stomatitis, oral mucosa rather dry and cyanosis.

j. Neck

Pemberasaran symmetrical no lymph nodes and no mass in the neck.

k. Chest

- Palmo:

Inspection: Symmetrical breast development, no chest retraction.

Palpation: Fremitus equally between left and right

Percussion: Sonor

Auscultation: Sounds basic vesicular, Ronchi (-), wheezing (-)

- Cast

Inspection: Ictus Condis not looked

Palpation: Ictus Condis palpable in SIC 5th

Percussion: Configuration in the normal range

Auscultation: heart sound I and II pure, no noisy or dark.

l. abdomen

Inspection: Stomach looked convex

Auscultation: Hiperperistaltik ( 20 x / min)

Palpation: No hepatomegaly, splenomegaly no

Percussion: Bloating.

m. genital

Complete no abnormalities, area around the genital and diaper moist / wet pengalas.

n. extremity

Better in muscle tonus, the warm akral, capillary refil 2 seconds, no cyanosis
installed a drip in his left hand.

o. Skin

The skin is clean, no lacerations, turgor less.

9) Examination Support

a. Laboratorium (7/1 2012)

Hemoglobin 10,30 gr % 11.00-13.00 L

Hematokrit 30,4 % 36.0-44.0 L

Eritrosit 3,71 jt/mmk 3.60-5.00

MCH 27,80 pg 23.00-31.00

MCV 82,00 fl 77.00-101.00

MCHC 33,90 g/dl 8.00-36.00

Leukosit 11,40 ribu/mmk 6.00-18.00

Trombosit 452,0 ribu/mmk 150.0-400.0 H

 Kimia klinik

Glukosa sewaktu 109 mg/dl (136-145)

Elektrolit

Natrium 140 mmol.L 136-145

Kalium 3,7 mmol.L 3,5-5,1

Khlorida 114 mmol.L 98-107 H

Calcium 2,49 mmol.L 2,12-2,50

materials blood

Secretion - excretion = faeces routine

Yellow

Consistency: soft, liquid

Micros: Ascaris: - LPK negative

Ankilostoma: - LPK negative

Trikhiuris: - LPK negative

Oxyuris: - LPK negative

Amoeba

A. Histolitikum - LPK negative

A. Coli - Negative LPK

Kista - LPK

Waste products - negative

Rest of the meal - negative

Remaining fat - negative

Remaining carbohydrates - negative

Remaining protein + / negative post

Meat offal - negative

The starch granule - negative

Glabul starch - negative

Glabul fat - negative

Remains of plant - negative

Sudan 3

Cells: Red blood cells - negative LPB

Leukocytes - LPB negative

Epithelium - LPB negative

Kans: Ascaris - negative

Ankilostoma - negative

Trikhirius - negative

Oxyuris - negative

Kista - negative

Bacteria + / negative post

Mushrooms - negative

b. Therapy

3B KAEN infusion 480/20/5 drops / min

Oralit 50 cc per diarrhea

PO:

- Paracetamol 3 x inc

- Ketokoazole 3 x 50 mg

- Vit. BC 3 x tab

- Vit. B6 3 x tab
Diit: 3 x servings of porridge tempe

8 x 60 cc LLM

Program

: General state supervision, TTV and signs of dehydration.