Nursing Care Plan Gastroenteritis

Assessment

Include systematic assessment of data collection, data analysis and determination of the problem. The collection of data obtained by means of intervention, observation, assessment psikal.

1. The identity of the client


2. History of nursing
   • Prefix attack: At first a whiny child, anxiety, increased body temperature, anorexia and diarrhea occur.
   • The main complaint: the more liquid Faeces, vomit, if losing a lot of water and electrolytes symptoms of dehydration, weight decreased. In infants large fontanel sunken, skin tone and decreased turgor, mucous membranes dry mouth and lips, CHAPTER frequency more than 4 times with watery consistency.
   
   
3. Medical history of the past
   Illness history, history of immunization.


4. Family psychosocial history.
   Will be treated stressor for the child itself or for the family, increased anxiety if the parent does not know the procedures and treatment of children, after realizing her illness, they will react with anger and guilt.


5. Basic needs
   • Pattern of elimination: the changes will have more than CHAPTER 4 times a day, a little bladder or rarely.
   • Pattern of nutrients: begins with nausea, vomiting, anopreksia, causing weight loss patients.
   • The pattern of sleep and rest will be disturbed because of abdominal distension that would cause discomfort.
   • Pattern of hygiene: the habit of bathing every day.
   • Activity: be disrupted because lamah body condition and the pain due to abdominal distension.
   
   
6. Physical examination
   • Psychological examination: general condition was weak, kesadran composmentis into a coma, high body temperature, rapid and weak pulse, breathing rather quickly.
   • Systematic Inspection :
     • Inspection: sunken eyes, large fontanel, mucous membranes, dry mouth and lips, decreased body weight, rectal redness.
     • Percussion: the existence of abdominal distension.
     • Palpation: less elastic skin turgor.
     • Auscultation: bowel sounds terdengarnya.

Nursing Diagnosis

1. Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.


2. Nutritional needs less interference than the body needs berhubuingan with nausea and vomiting.

Intervention

Diagnosis 1.
Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.

Destination:
Fluid and electrolyte Devisit resolved

Criteria results:
Signs of dehydration are not there, mouth and lip mucosa moist, well-balanced fluid exchange

Intervention
Observation of vital signs. Observation of signs of dehydration. Measure the liquid infut and output (balanc ccairan). Provide and encourage families to provide a lot of drinking more or less 2000 - 2500 cc per day. Collaboration with physicians in providing therafi fluid, electrolyte lab tests. Collaboration with a team of nutrition in low-sodium fluids.


Diagnosis 2.
Nutritional needs less interference than the body needs berhubuingan with nausea and vomiting.

Destination:
Nutritional needs disturbances resolved

Criteria results:
Clients increased nutritional intake, low dietary portion 1 provided, nausea, vomiting does not exist.

Intervention:
Examine patterns of clients and nutritional changes. Measure client weight. Examine factors cause the fulfillment of nutritional disorders. Perform physical examination of the abdomen (palpation, percussion, and auscultation). Give your diet in warm conditions and the small but frequent portions. Collaboration with the team in determining diet nutrition clients.