nursing care

NURSING PROGRAM OF MALANG

Nursing Care PlanDeficient Fluid Volume

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Group 2Lilis N Aida(1301100002)GentaMahendra(1301100003)Kevin Septian(1301100016)Nurul Qomariah(1301100045)

HEALTH POLYTECHNICMINISTRY OF HEALTH MALANGSTUDY PROGRAM D-III NURSING OF MALANGDyahAyu R(1301100059)

Nursing Form

A. Assessment

1.DATA COLLECTIONA. IDENTITY 1) Name: Mr.K2) Sex : Male3) Age : 75 years old4) Marriages status : Marriage5) Work : Enterpreuner6) Religion : Moslem7) Last Education : Not completed primary school8) Address:Blimbing village, Malang City9) Date of admission:Wednesday. 3rd September 2014

B. Medical Diagnose: Mild anemiaand melena

C. Main complaintClient says his body gets weak, his head gets dizzy, sometimes gets hurt on his leg, when he wants to defecate his stomach is sick, and the faecess color is black.

D. Profile of Present IllnessClient says his body gets weak during 5 days before he get hospitalized, and he gets tired when doing activities. When his family know hedefecated black faeces, his family carried him to go to hospital. After he get check up, he must get hospitalization and now he is inAirlanggas room.

E. Profile of Past IllnessClients wife says that her husband never get sick before

F. Profile of Familys HealthClients wife says he has no had hereditary disease

G. Daily Activity1) Meal and drinkBefore hospitalized (meal) : Client has meal 1 until 2 times in a day After hospitalized (meal) : Client has meal 5 spoons in a day. Before hospitalized (drink) : Client has drank about 1500 ml of water in a dayAfter hospitalized (drink ) : Client has drank less than 1000 ml in a day

2) Elimination Before hospitalized (defecate) : once in a day, constipation (-), yellowish faeces.After hospitalized (defecate) :about 3 times in a day, liquid stool, black faeces. Before hospitalized (urin output) :about 3 times in a day, yellowish urine, urines volumeabout 1500 ml/dayAfter hospitalized (urin output) :about 5 times in a day, tea color of urine, urines volume less than 1500 ml/day

3) Restand SleepingBefore hospitalized: Client has sleeping time about 8 hours in a dayAfter hospitalized: Client has sleeping time about 6 hours in a day, client often get up because he feels pain in his stomach and get urination

4) Personal HygieneBefore hospitalized: client takes a bath twice in a day,brushes his teeth and shampoo by himselfAfter entering hospital : client only gets swapping in a day or sometimes he does not, not brushing his teeth or shampooing, but his wife always helps client to get clean.

H. Profile of PsychosocialHis family says that client is anxious about his disease.

I. Physical Examination1) General ConditionClients condition is weak, his face is pale and dizzy

2) Vital SignHeart Rate: 70x/minuteTemperature: 37 cBlood presure: 100/70 mmHgRespiration : 18 x/minute

3) Head and necks inspection :Head:Face is symmetricalHair :Alopesia (-)Eyes :Konjungtiva: RedPupil: IsochoreSclera: WhiteSianosis: (-)Icterus : (-)Nose:Normal, polyp : (-)Mouth:Stomatitis (-), cavity (-) , teeth color are yellowish

4) IntegumensinspectionTurgor: Good, skinelasticity is back in seconds. Injury: (-)Cyanosis: (-)Icterus: (-)Skin moisture: dry

5) Chest and thoraxLung :I: symmetrical, injury (-) P: wheezing (-), ronchi (-)P: presure pain (-)A: sonor Heart :I : icturecordis (-)P : heart Sound 1 (+), Heart Sound 2 (+)P : enlargement of the heart border (-)A : deaf

6) ChestChest is symetrical, ginikomasti (-)

7) AbdomenI: tumor (-)P: tympaniP: presure pain (-)A: peristaltic is 30x/minute

8) GenetaliaBefore hospitalized: normal, client always cleans by himself twice in a dayAfter hospitalized: normal, but client cleans the body sometimes

9) ExtremitasUpper extremity: odeme (-), symetrical, on the right hand pair of infusUnder extremity: odeme (-), symetrical, normal

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Mucles strength:

10) Neurological ExaminationPatient feel dizzy, sometimes the feet fells pain

11) Laboratory ExaminationHb= 8,6Leukosit= 12.010

12) Curative TherapyKalnex= 2x50Ranitidin= 3x50Metaclo= 3x5

2. DATA ANALYSIS

DATA ANALYSIS

Name: Mr. KAge: 75 years oldRegister:357216

SignProblemEtiologi

Subjective Data Patient said he is weak, have a stomachache, seldom to eatObjective Data Urine color is dark yellow, amount of input 2500cc/24 hours, output at least 1750cc/24 hours, the color of feces is rather darkish impuls: 70x/minute, blood pressure: 100/70 mmHg, temperature: 37 degree celcius Intake of water: at least 1000cc/day Output of urine: at least 1500cc/day Intake of food: at least 6 servings Output of feces: at least 50cc/day (with melena)Hb: 8,6Amount of fluid is increaseIntake and output arent good

Subjective Data Patient said that he always need help when he was doing his activityObjective Data Impulse: 70x/minute Blood pressure: 100/70 mmHg Temperature: 37 degree celcius Respiratory: 25x/minute CRT: good Muscle power 3 3

3 3Activity: take a bath and walk =needs help, sit= he an do it by him self, stand= he needs help, eat= he needs help, drink= he can do it by himselfActivity intoleranceProcess of healing

Subjective data Patient said that he is seldom to take a bath, he take a bath 1x/day, he doesnt brush his teethObjective Data There is a grime His breath is stinky His toungue is dirty His body is stink and dirtyHe wasnt care himself wellInability

Subjective data Patient said that he is seldom to take a bath, he takes a bath 1x/day, he doesnt brush his teethObjective Data There is a grime His breath is stinky His toungue is dirty His body is stinky and dirtyHe wasnt care himself wellInability

NURSING DIAGNOSIS

1. Deficit fluid volume associated with inadequate intake and output characterized by high water intake and low water discharge (found at 8/9 2014).2. Activity intolerance related to the healing process characterized by not able to do activity (found at 8/9 2014).3. Self care deficit related to the inability characterized by infrequent bathing, bad breath, body odor (found at 8/9 2014).

NURSING INTERVENTION

Name: Mr. KAge: 75 years oldRegister: 357216

DateNo. of DiagnosisGoals and Expected CriteriaIntervention Rasional

9/9/141After receiving nursing care for 24 hours, patient is expected to have a balanced intake and output.

1. Monitor vital signs2. Auscultation of the lungs and heart sounds3. Assess the edema4. Monitor distended neck and peripheral veins5. Maintain accurate input and output6. Check weight scale as indicated7. Monitor infuse rate8. Maintain semi-Fowler position when the patient tightness

1. Tachycardia and hypertension are common manifestation2. Adventius breath sounds and extra heart sounds are indications3. Edema can occur in patients with fluid excess4. Signs of cardiac decompensation5. Decresed renal perfusion, cardiac insufiension6. 1 liter of fluid retension = Weight gain of 1 kg7. Quick cause of excessive fluid8. Gravity improve lung expansionand lower diaphragm

9/9/142After receiving nursing care for 24 hours, patient is expected to: participate in physical activity without an increase in blood pressure, pulse, and respiration rate able to perform activities of daily living independently1. Observation of the restrictions on the client in an activity2. Assess for factors that cause fatigue3. Monitor nutrition and adequate energy source4. Monitor patients existence of physical and emotional exhaustion in excess5. Monitor cardiovascular response to activity6. Monitor sleep time and lifestyle of patients,7. Collaboration with medical rehabilitation personnel in planning appropriate therapy programs8. Help clients to identify activities that is able to do it1. Documentation to which the activities of the patient2. Determine the cause of fatigue clients3. Providing enough energy to perform the activity4. Limiting excessive activity5. Knowing the increased cardiovascular or not6. Knowing how long break so knowing the client is ready to exercise or not7. Quick healing for clients8. Knowing activities that have been carried out and the continuation of the next exercise

9/9/143After receiving nursing care for 24 hours, patient is expected to:shows self-care activities in the level of personal abilities1. Specify the current capability (0-4 scale) and barriers to participate in treatment2. Patients in the formulation includes care plan at the level of ability3. Encourage self-care4. Use special equipment as needed5. Provide appropriate personal hygiene needs6. clothing by modifying the buttons as indicated7. Help clients get cleaned up1. Identify the needs of a given2. Increasing the feeling of control and promote cooperation and development of self-reliance3. Do activities by himself and increase feelings of self-esteem4. Improve the ability to move or showing his ability to be active safely5. Helping maintain the appearance6. Helping to quicken the taking clothing7. Reduces the risk of dental disease or tooth lost

NURSING IMPLEMENTATION


Date/TimeNo. of DiagnosisImplemantation

8/9/1402.00 pm1,3

2

3 measure and record vital signs measure and record intake and output, urine and stool color observation observation of bleeding

measure and record vital signs before or after passive motion exercises invites passive motion exercises record progress client increase exercise if client able to do it

helping client to get clean up such as bathing, brushing teeth, changing clothes patient motivating the client's willingness to take a bath by himself

9/9/1407.001,3

2

3 measure and record vital signs measure and record intake and output, urine and stool color observation observation of bleeding measure weight of client

increase exercise if client is able to do it measure and record vital signs before or after passive motion exercises

observe the ability of client let the client bath by himsel if possible encourage the willingness of patient to improve personal hygiene

FORMATIVE EVALUATION


No. of DiagnosisDate : September 8th 2014Date: September 9th 2014

1S : Patient feel weakl, feces rather black, and apteint feel painful in abdomen

O: Urine = yellow, 1500cc/day Feces = black, 50cc/day Intake = 2500cc/hour Output = 1750 cc/hour Mucous = dry Elastic skin = good conjungtivity = pale

A: The problem has not been solved

P : Advanced interventionS : Patient feel weak, feces swit but the colour is black, and painful in abdomen be lost

O : Urine = cler, 1000cc/day Feces = black, 50 cc/day Mucous = moist Elastic skin = good conjungtivity = pale


P : Advanced intervention

2S : Patient said that wife assisted his activities

O: strength of muscle33

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Pulse = 70 x/minute Temperature = 370c Blood Preasur =100/70 mmHG patient just sitting, staning, walking, eating, drinking and all his activity assisted by the wife


P : Advanced interventionS : Patient is able to stand, and walk alone but acompanied by his wife

O : strength of muscle33

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Pulse = 68 x/minute Blood presure = 110/70 x/minute Temperature = 36,6oc Patient just siting and patient able to take drinking, eating and taking a bath but still controled by nurse


P : Patient discharged

3S : Patient said he had a bath, shower only once a day, and even then only atoothbrushing and shampooing

O: breath and body odor are typical, clothes looks shabby, and patient is less excited.

A: The problem been solvedP : Advanced interventionS : the patient said he had a shower

O : breath and body odor diminish, clothes look neat, and patient start smiling

A: The problem been solvedP : Patient discharged

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