B. Nursing Diagnosis
I. Impaired tissue perfusion related to decreased oxygenation to the cells - cells with the patient ditadai said head feels dizzy,, pale skin color, lips look dry sclera jaundice, cold extremities, N; 70x / m, R: 45 X / m
Objective: tissue perfusion disturbances resolved
NOC: Tissue perfusion: peripheral
criteria:Ø
• Vital signs normal N: 80-110. R: 20-30 x / m
• Warm Ektremitas
• Skin color is not pale
• Does the sclera jaundice
• Lips not dry
• Normal Hb 12-16 g%
NIC: Monitoring Vital sign
INTERVENTION
1. Observation of Vital Signs, Skin Color, Consciousness, and state level Ektremitas
2. Adjust the position of Semi Fowler
3. Collaboration With Doctor Giving Blood transfusion
4. Giving O2 when necessary
II. Fluid volume and electrolyte deficit associated with decreased input (vomiting) is characterized by patients taking less than 2 gls / day, oral mucosa dry, skin turgor slow return, less urine production.
Objective: fluid volume deficit and electrolyte resolved
NOC: Control of fluid
criteria:Ø
• Patients drank 7-8 cups / hr
• moist oral mucosa
• Skin turgor get back less than 2 seconds
NIC: Management of liquid
INTERVENTION
1. Onservasi Output Fluid Intake
2. Observation of Vital Signs
3. Give the patient drink little by little
4. Forward parenteral fluid therapy in accordance with the doctor's instructions
III. Impaired sense of comfort (pain) associated with the diatandaoi penigkatan peristaltuk with tenderness in the left upper quadrant abdominal region, hipertimpani abdomen, abdominal distension, intestinal peristaltic 10 x / m
Objective: gannguan sense of comfort (pain) resolved
NOC: pain control
expected outcomes:
• Abdominal pain disappeared or less
• Abdomen tympanic (percussion)
• Abdominal distention is not
• normal bowel peristaltic
NIC: Pain Management
INTERVENTION
1. Assess complaints of pain, location, duration and intensity
2. Give the pot of hot / warm at area hospital
3. Do it gently massage the area of pain
4. Collaboration of analgesic drugs
C. Evaluation
I. Impaired tissue perfusion related to decreased oxygenation to the cells - cells with the patient ditadai said head feels dizzy,, pale skin color, lips look dry sclera jaundice, cold extremities, N; 70x / m, R: 45 X / m
NOC: Tissue perfusion: peripheral
with the following criteria:
• Vital signs normal N: 80-110. R: 20-30 x / m
• Warm Ektremitas
• Skin color is not pale
• Does the sclera jaundice
• Lips not dry
• Normal Hb 12-16 g%
II. Fluid volume and electrolyte deficit associated with decreased input (vomiting) is characterized by patients taking less than 2 gls / day, oral mucosa dry, skin turgor slow return, less urine production.
NOC: Control of fluid
with the following criteria:
• Patients drank 7-8 cups / hr
• moist oral mucosa
• Skin turgor get back less than 2 seconds
III. Impaired sense of comfort (pain) associated with the diatandaoi penigkatan peristaltuk with tenderness in the left upper quadrant abdominal region, hipertimpani abdomen, abdominal distension, intestinal peristaltic 10 x / m
NOC: pain control
expected outcomes:
• Abdominal pain disappeared or less
• Abdomen tympanic (percussion)
• Abdominal distention is not
• normal bowel peristaltic
REFERENCES
Doenges, Marillyn E. 1999.Rencana Nursing.
3.Penerbit Edition Medicine Books EGC
Ngastiyah.1997.Perawatan Sick Children. Medical Book Publishers EGC.Jakarta
Sodeman.1995.Patofisiologi.Edisi 7.Jilid 2.Hipokrates.Jakarta
I. Impaired tissue perfusion related to decreased oxygenation to the cells - cells with the patient ditadai said head feels dizzy,, pale skin color, lips look dry sclera jaundice, cold extremities, N; 70x / m, R: 45 X / m
Objective: tissue perfusion disturbances resolved
NOC: Tissue perfusion: peripheral
criteria:Ø
• Vital signs normal N: 80-110. R: 20-30 x / m
• Warm Ektremitas
• Skin color is not pale
• Does the sclera jaundice
• Lips not dry
• Normal Hb 12-16 g%
NIC: Monitoring Vital sign
INTERVENTION
1. Observation of Vital Signs, Skin Color, Consciousness, and state level Ektremitas
2. Adjust the position of Semi Fowler
3. Collaboration With Doctor Giving Blood transfusion
4. Giving O2 when necessary
II. Fluid volume and electrolyte deficit associated with decreased input (vomiting) is characterized by patients taking less than 2 gls / day, oral mucosa dry, skin turgor slow return, less urine production.
Objective: fluid volume deficit and electrolyte resolved
NOC: Control of fluid
criteria:Ø
• Patients drank 7-8 cups / hr
• moist oral mucosa
• Skin turgor get back less than 2 seconds
NIC: Management of liquid
INTERVENTION
1. Onservasi Output Fluid Intake
2. Observation of Vital Signs
3. Give the patient drink little by little
4. Forward parenteral fluid therapy in accordance with the doctor's instructions
III. Impaired sense of comfort (pain) associated with the diatandaoi penigkatan peristaltuk with tenderness in the left upper quadrant abdominal region, hipertimpani abdomen, abdominal distension, intestinal peristaltic 10 x / m
Objective: gannguan sense of comfort (pain) resolved
NOC: pain control
expected outcomes:
• Abdominal pain disappeared or less
• Abdomen tympanic (percussion)
• Abdominal distention is not
• normal bowel peristaltic
NIC: Pain Management
INTERVENTION
1. Assess complaints of pain, location, duration and intensity
2. Give the pot of hot / warm at area hospital
3. Do it gently massage the area of pain
4. Collaboration of analgesic drugs
C. Evaluation
I. Impaired tissue perfusion related to decreased oxygenation to the cells - cells with the patient ditadai said head feels dizzy,, pale skin color, lips look dry sclera jaundice, cold extremities, N; 70x / m, R: 45 X / m
NOC: Tissue perfusion: peripheral
with the following criteria:
• Vital signs normal N: 80-110. R: 20-30 x / m
• Warm Ektremitas
• Skin color is not pale
• Does the sclera jaundice
• Lips not dry
• Normal Hb 12-16 g%
II. Fluid volume and electrolyte deficit associated with decreased input (vomiting) is characterized by patients taking less than 2 gls / day, oral mucosa dry, skin turgor slow return, less urine production.
NOC: Control of fluid
with the following criteria:
• Patients drank 7-8 cups / hr
• moist oral mucosa
• Skin turgor get back less than 2 seconds
III. Impaired sense of comfort (pain) associated with the diatandaoi penigkatan peristaltuk with tenderness in the left upper quadrant abdominal region, hipertimpani abdomen, abdominal distension, intestinal peristaltic 10 x / m
NOC: pain control
expected outcomes:
• Abdominal pain disappeared or less
• Abdomen tympanic (percussion)
• Abdominal distention is not
• normal bowel peristaltic
REFERENCES
Doenges, Marillyn E. 1999.Rencana Nursing.
3.Penerbit Edition Medicine Books EGC
Ngastiyah.1997.Perawatan Sick Children. Medical Book Publishers EGC.Jakarta
Sodeman.1995.Patofisiologi.Edisi 7.Jilid 2.Hipokrates.Jakarta
