NURSING HEALTH HISTORY

“GASTROENTERITIS”
Disusun untuk Memenuhi Tugas Mata Kuliah Bahasa Inggris Keperawatan I

Dosen :

Hj. Evi Risa Mariana, S.Pd, M.Pd

Disusun Oleh :
Nor Mahdiyah NIM 7120117069

Norvansyah Al Fahrizi NIM 7120117071

Nurrany Fitriani NIM 7120117072

Ulfah NIM 7120117084

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN BANJARMASIN
JURUSAN DIII KEPERAWATAN
2018/2019
1. Biographic Data
Name : Mrs. T
Age : 19th
Sex : Female
Race : Java
Address : Jl. Ahmad Yani
Marital status : Single
Occupation : Indonesian
Religious orientation : Islam
Diagnose : Gastroenteritis (GE)
2. Chief Complaint or Reaseon for Visit
a. On arrival in the hospital : patient complain of his stomach feeling heartburn,
fever, diarrhea, accompanied by vomiting.
b. During the assesment patients said his stomach was heartburn and felt weak.
3. History of Present Illness
Mrs.T said his body was hot two days ago, defecated five times a day. His
feces is yellow-green and accompanied by mucus, and accompanied by vomiting
twice a day, and then taken yo the nearest hospital.
4. Past History
Mrs. T has never suffered from this illness before. She had previously never
been hospitalized. She said previously not the same disease as experience now, she
also said there is no history of gastroenteritis disease. She only experience disease
such as cough and colds.
5. Family History of Illness
Mrs. T said there are also families who suffer from the same disease.
6. Life-Style
Which became a personal habits of Mrs. T is likes to eat spicy food everyday
and she often drink cola. It’s the habit that makes it diarrhea. If she doesn’t eat spicy
and often drink cola, then chances are she will not become diarrhea.
7. Social Data
Mrs. T is a student living alone and away from his family. when she is sick
,she will contact his parent.or tell her collage friends.
8. Psychologic Data
General conditions appear weak, composmentis kesadran to coma, high body
temperature, pulse fast and weak, breathing rather quickly.
9. Patterns of Health Care
The pattern of care performed on the patient is the first to know. The fluid
volume and electrolyte deficit is less than the body's needs associated with excessive
fluid output by observing vital signs, observing the signs of dehydration, measuring
fluid input and output, giving and suggesting family to give a drink of approximately
2000-2500 cc per day, collaborating with the doctor in administering the theraphy of
the electrolyte lab examination fluid and collaborating with the nutrition team in
administering low-sodium liquids.
Then the second one should examine the nutritional deficiencies less than the
body needs associated with nausea and vomiting such as assessing the client's
nutritional pattern and changes that occur, weighing the client's weight, assessing the
causes of nutritional obstacles, performing the physical examination of the abdomen
(palpation, percussion, and auscultation), giving the diet in warm conditions and small
portions but often.
Furthermore, we should also examine the discomfort of pain relating to
abdominal distension. which we can examine, among others, is to assess the level of
pain, set a comfortable position for the client, give warm compresses to the abdominal
area, and collaborate with the doctor in giving analgesic therafi as indicated.