Nursing Care for

Patient with Diarrhea

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.

Head to Neck Assessment
Eye : conjungtiva anemis (-), sclera
icteric (-), oedem palbebra (-), sunken
eyes
Nose : symmetric, polip (-), secret (-)
Mucosa : dry
Neck : jugular venous distenstion (-)
Ear : secret (-), symmetric

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


Intervention
Implementation

Evaluation