NURSING PROGRAM OF MALANG

Nursing Care PlanDeficient Fluid Volume

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Group 2Lilis N Aida(1301100002)Genta Mahendra(1301100003)Kevin Septian(1301100016)Nurul Qomariah(1301100045)Dyah Ayu R(1301100059)HEALTH POLYTECHNICMINISTRY OF HEALTH MALANGSTUDY PROGRAM D-III NURSING OF MALANG

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 admitted:Wednesday. 3rd September 2014

B. Medical Diagnose: Mild anemia and melena

C. The Main complaintClient say his body get weakness, his head get dizzy, sometimes get hurt on his leg, when he want to defecate his stomach is sick, and the faecess color is black.

D. Profile of Present IllnessClient say his body get weak during 5 days before he get hospitalized, and he get tired when do activities. When his family know he defecated black faeces, his family is carry him go to hospital. After he get check up, he must get hospitalization and now he is in Airlanggas room.

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

F. Profile of Familys Health Clients wife say not 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 drink about 1500 ml of water in a dayAfter hospitalized (drink ) : Client has drink less than 1000 ml in a day

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

3) Rest and SleepingBefore hospitalized: Client has sleep time about 8 hours in a dayAfter hospitalized: Client has sleep time about 6 hours in a day, client often get up because he feel pain in his stomach and get urination 4) Personal HygieneBefore hospitalized: client is take a bath 2 times in a day, brush his teeth and shampooing by himself After enterned hospital : client only scrubing in a day or sometimes he do not, not brush his teeth or shampooing, but his wife always help client to get clean.

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

I. Physical Examination1) General ConditionClients condition is weak, his face is fright 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 yellowness

4) Integumens inspection Turgor: Good, skin is back in second. 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 cleaned by himself second in a dayAfter hospitalized: normal, but client clean it sometimes

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

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Mucles strength:

10) Neurological ExaminationPatient feel dizzy, sometimes the feet fell 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 dark, 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 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 a help when he was doing his activityObjective Data Impuls: 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 =need a help, sit= he an do it by him self, stand= he need a help, eat= he need a 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 dont brush his teethObjective Data There is a grime His breath is stink His toungue is dirty His body is stink and dirtyHe wasnt care himself enoughInability

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

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: 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 excess fluid8. Gravity improve lung expansion and 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 do1. 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. Healing memperepat 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 includer care plan at the level of ability3. Encourage self-care4. Use special equipment as needed5. Provide appropriate personal hygiene needs6. Get clothes 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 for themselves and increase feelings of self-esteem4. Improve the ability to move or show activity safely5. Helping maintain the appearance6. Helping mempercept process of disposing of clothing7. Reduces the risk of dental disease or loss tooth

NURSING IMPLEMENTATION

Name: Mr. KAge: 75 years oldRegister: 357216

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

helping client get cleaned 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 weigh of client

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

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

FORMATIVE EVALUATION

Name: Mr. KAge: 75 years oldRegister: 357216

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 Konjungtiva = pale

A: The problem is not can be overcome

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 Konjungtiva = pale

A: The problem is not can be overcome

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 wife

A: The problem is not can be overcome

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

O : strength of muscle 33

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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

A: The problem is can be overcome

P : Patient go home

3S : Patient said they had a bath, shower only once a day, and even then only atoothbrush and shampo

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

A: The problem is not can be overcomeP : 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 is can be overcomeP : Patient go home