Age : 8 days
Date Added : 6 August 2011
Name : By. S
Diagnosis : post op colostomy the indication atresia ani
NO | DATA | Diagnosis | PLANNING | IMPLEMENTATION | EVALUATION | ||
PURPOSE | INTERVENSI | RATIONAL | |||||
1. | Ds: the patient's mother said her son fussing, crying Do : - The patient seemed agitated installed colostomy - The existence of tenderness. - HR 120x / min - RR 30 x / min - Temp 37.6 ° C - Scale pain 6 (medium) | Disorders of the needs of comfort: painassociated with incision surgery d / d patient's mother said patients seemed, often crying and weak, Kien was restless, cranky, attached kolostomy, a scar on the left side of the abdomen, the pain hit, HR 120 x / I, RR 30 x / I, Temp 36.4, pain scale 6 (medium) | In 3x24 hours wktu pain tolerance can be the criteria: Ø Clients look cool Ø No fuss Ø HR 90 x / i RR Ø 28 x / I | 1. Observation of the patient's general condition 2. Assess the degree of pain, and vital signs 3. Avoid actions mempalpasi stoma area except when in need 4. Perform actions entertain patients 5. Encourage the family to watch her baby activity 6. Perform collaboration analgetik | Knowing the patient's condition Knowing the pain scale and vital signs With the pressure on the injured area may increase Distract baby Activities that are not controlled can cause pain. Eliminating pain | 1. observing Patients general condition each 1 x 2 hour: Appeared patient calm 2. assess the degree of pain: the scale of 6 (moderate), HR 120 x / I, RR 30x / I, temp 36.4, 3. avoid action mempalpasi the wound too long 4. did act funny in a patient such as: say "Cilubba" 5. suggested to the family to observe patient activity in order to Prevent the onset of pain 6. provide injection: tramadol 20 mg / 8 hours | S: Mom patients say his son was fussy. O: - the patient seemed quiet - HR: 100 x / i - RR: 29 x / i - Temp: 36.4 ° C - Pain scale 5 (lighter) A: Comfortable Sense of Pain Disorders Q:'s continued intervention |
2 3. | Ds: the patient's mother said her son was weak, decreased appetite latching do: - The patient was weak, - The desire to breastfeed reduced. - Bowel increased by 24 x / i - BB before entering the hospital 3 kg - BB hospitalized after 2.2 kg 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, | Impaired nutritional needs less than body requirements associated with poor nutritional d / d patient's mother said her son was weak, increased bowel sounds 24 x / minute, before BB MSUK Hospital 3 kg, after entering Runah Pain 2.2 kg Damage to skin integrity associated with stoma associated with Mom patients say leather around the stoma her stomach looks rosy, the skin looks red, the skin around the stoma Integrity bad, the stoma, stoma ± 3cm wide | 3x within 24 hours of nutrition disorders may improve later resolved d / k: - Patients looking cheerful - Normal Bowel - Mucosa moist lips - Baseline After wound care can achieve recovery without complications | 1. Perform auscultation for bowel sounds Weight Loss 2. Timbang regularly 3.Anjurkan mother give milk on a regular basis Collaboration with physicians enteral feeding 4.Kolaborasi enteral feeding with your doctor 1. Monitor TTV as often as possible. Pehatikan adnya tachypnea, tachycardia and tremor 2. Check the area around the stoma with often the swollen 3. Encourage parents fatherly megganti colostomy bag every time a bag full 4. Apply ointment around the abdominal wall all the replacement bag 5.Lakukan irrigation when the skin around the stoma | 1. Knowing the frequency of bowel 2. Knowing whether there was a decrease Weight Loss 3. Meet adequate nutrition 4.Kelemahan kibat intolerant operation on the input / oral 1. Perhaps an indication of infection slows wound healing 2.Mengindikasikn infection 3.Membiarkan bag is too full it can increase the risk of a leak in the bag 4. Can help accelerate the return of skin integrity 5. perform irrigation can prevent infection and odor | 1. Perform auscultation for bowel sounds: 24x/menit 2. weigh every morning after waking up, BB: 4.1 kg. 3. Encourage the mother to breastfeed every 2 hours 4. Installing NGT to provide enteral feeding . Measuring vital signs every 5 minutes once Temperature: 36.7 C Nadi: 120x/menit Respiratory: 30 x / min 2. Monitor whether there are signs infeksic: rubor, dolor, calor, tumor, lesion function 3. Encourage the parents fatherly change a colostomy bag when the bag is full 4. Ointments around the abdominal wall every do penggantin bandage and replacement bags 5. Doing irrigation of the stoma with water or saline fluid 2x/day | S: Mom says her client is still weak O: -Client looks weak - BB: 2.4 kg -mucosal dry lips A: Disorders of nutrition Q: Intrvensi continued S: Mom patients say skin around the scar on her stomach is still rosy O:-skin look red -The integrity of the skin is still ugly P: Interventions continued |
