No | DATA | ETIOLOGY | PROBLEM |
1 | DS: Mom patients say their children often cry and fuss weak DO: - client appears agitated and fussy - Installed colostomy - The tenderness - HR: 120 x / i - RR: 30 x / i - Temperature: 37.6 ° C - Pain scale 6 (medium) | Incision Surgery, Termination Networks, painful | Impaired sense of comfort: pain |
2 | DS : Ibu pasien mengatakan anaknya tampak lemah DO : - pasien tampak lemah - bising usus meningkat 24x/i - BB sebelum masuk RS 3 Kg - BB sesudah masuk RS 2,2 Kg | Lack of Nutritional Physical weakness Fulfillment Disorders Nutrition Needs of less than | Disorders Nutrition Fulfillment less of a need |
3 | DS: Mom patients say leather around the stoma her stomach look red. DO:-skin look red -The integrity of the skin around the stoma bad -the stoma - ± 3cm wide stoma, | Making stoma Spending feces of Stoma Excessive damage to skin integrity / value of patents not yet | Damage Skin Integrity |
Nursing Diagnosis Priorities
1. Impaired sensenayaman: Pain
2. Impaired nutritionalneeds less than body requirements
3. Damage to skin integrity
Nursing Diagnosis
1. Impaired sensenayaman: Pain
2. Impaired nutritionalneeds less than body requirements
3. Damage to skin integrity
Nursing Diagnosis
- Impaired sense of comfort: pain b / d incision surgery d / d patient's mother said her son fussing and crying, looked nervous client, installed colostomy, the tenderness, pulse:120 x / min, respiration: 30 x / min, temperature: 37 , 6 oC, pain scale 6 (moderate).
- Disorders of nutrition less than body requirements b/ d poor nutritional d / d patient's mother said her son was weak, drinking milkdecreased appetite, patients appear weak, reduceddesire to breastfeed, increased bowel sounds 24 x / i, BB beforehospital admission 3 kg, was hospitalized after BB2.2 kg.
- Damage to skin integrity b / d stoma d / d mother Asien said the skin around the scar descending colon looks red,, the integrity of the skin around the stoma bad, the stoma, stoma± 3 cm wide.
