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NURSING CARE OF Mr.

A M WITH
DIAGNOSE DEFICIT ELECTROLYTES
FLUID RELAATED TO LOSE THE
LIQUID ACTIVE
IN CEMPAKA II ROOM OF RSUD RAA
SOEWONDO PATI
Support Lecturer: Sutarmi, Mn

Arranged By: Dwi Ayu Kartika Sari (P1337420417031)


Case Review
Assasment
 Name: Dwi Ayu Kartika Sari

 Place: Cempaka 1 Room RSUD Soewondo Pati

 Date: 29 October – 27 Nopember 2018


A. Assasment
1. Biodata
Name : Mr.M
Age/date : 15 years old / 16-12-2002
Last education : Junior high school
Gender : Male
Religion : Islam
Status of mental : Coorperatif
Addres : Wonorejo 5/1 tlogorejo, Pati central java
Hospital admission date : 10-11-2018
No. registrasi : 216954
Diagnostic medic : Hiperthermi
 Person responsibly

Name : Purwono
Age : 55 years old
Addres : wonorejo 5/1 tlogorejo, Pati central java
Family Relationship with client :client’s father
 Main complaint : patient say hot and felt thirsty

 Current Medical history : An. M went to RAA soewundo


general hospital on 10 nopember 2018 14.30 p.m. with a
complaint heat up and down from one week ago. Yesterday
client don’t wanna ate because he had stomatitis. And he just
drink one glass. Defecate liquid twice and pass urinenate
smoothly.

 Past Medical History : the mother of patient said he had scabies


disease

 Family medical history : the mother if patient said


there was no decreased history and no one experienced pain as
suffered bt the patient
 Physical examination:
Common :languid
Appearance :Thin
Awareness :E4V5M6
Blood pleasure : 100/60 mmHG
Pulse :110x/mnt
Body temperature :39 C
Respiratory : 24x /mnt

Head : form of head: normochepale


Hair : clean
Scalp : clean don’t have dandruf

Eyes : sclera: non icteric


Konjungtiva : non anemis

Nose ; there is no secret and the function olfactory is normal


e. Ears : painful: nothing
Serumen liquid : nothing
Inflammation : nothing

f. Mouths :lip: pale and chapped lips


Mouth : dry
Tooth : clean
Gums : don’t sweeling and no bleeding
Tongue :clean
Stomatitis : nothing

g. Neck : stiff sitting: nothing


Trouble swallow : swallow
Enlargement of the glands: nothing

h. Chest: shape : symmetrical


Expansion of the lung : symmetrical
The sound of breath : vesicular
i. Heart: chest pain : nothing
The sound of heart : regular

j. Abdomen: the pain press: nothing


Bump : nothing
Acites : nothing

k. Musculoscletal : the power of tonus muscle:


5 5
5 5
Stiff joint : nothing
Trauma and pain : nothing
Skin : pale
IWL of Mr. M
Weight : 41 Kg
Age : 15 th
Temperature : 38 C

IWL for children =(30- the age of children in years) X cc/kgBB/day


= (31-15)X41Kg
=15X41
=615 cc

IWL to raise the temperature of the child =IWL + 200 (temperature-36,8 C)


=615+200(38-36,8)
=615+200(1,2)
=615+240
=855 CC
Balance fluid:
Input:
The liquid Ivs :1500 cc
Injection : 20 cc
AM : 5X41 : 205cc
Water : 900cc
Total :2625 cc
Output:
Urine : 1500cc
Vomit : 200 cc
Defecate : 200 cc
Iwl : 855cc
Total : 2755 cc

balance fluid: input –output


=2625-2755
=-130cc
Functional pattern system:
Nutrition
Before getting illness:
Frequency : 3X a day
Portion : medium, up
Kind : rice vegetable fruits,soft and taste
During getting illness:
Frequency : 3x a day
Portion : medium and half portion
Kind : rice vegetable,fruits,milk and soft
Rest and sleep:
Before getting illness:
Frequency : 2x/day
Quantity of take a nap :-
Quantity of night’s sleep : 7-8 hours
During getting illness
Frequency : 2x/day
Quantity of take a nap : 2 hours
Quantity of night’s sleep : 6-7 hours
Elimination
Before getting illness
Elimination of urine
Frequency and quantity : 4x/day 1200 cc
Color : yellow clear
During getting illness
Frequency and quantity : 5-6x/day 1000cc
Color : yellow

Elimination:
Before getting illness
Frequency :1x/day
Color : tawny brown color
Consistency : soft
During getting illness
Frequency : 1 x/2 day
Color : tawny brown color
Consistency : soft
Personal hygiene
Before getting illness
Take a bath :2x/day
Washing hair :1x/2 day
Clean the teeth and mouth : 2x/day
Change of clothes :3x/day
Clean the foot and finger nail 1x/6 day
During getting illness
Take a bath : 2x/day (sibin)
Washing hair : during in the hospital never wash his hair
Clean the teeth and mouth: 2x/day
Change of clothes : 2x/day
Clean the foot and finger nail: during in the hospital never clean his finger
nail
Therapy
 Infus Asering 20/dpm

 Injection iv ezola 1x1 amp

 Injection iv ceftiaxone 2x1 gr

 Injection iv ondansetron 2x1 amp

 Infus pet RL 3x500


Examination The Results Unit Reference value
Hematology
Leukocyte 8,4 10^3/UL 3.8-10.6
Erythrocytes 5.91 10^6/UL 4.7-6.1
Hemogobin 14,6 g/dl 11-15
Hematocrit 41.5 % 82-92
MCV L 70,2 fL 27-31
MCH L 24,7 Pg 32 36
MCHC 35,2 % 150-400
Platelets L87 10^3/UL 11.5-14.5
RDW-CV 14.5 % 35-47
RDW-SD 35,9 fL 9.0-13.0
PDW H 13,8 fL 35-47
MPV H 10.2 fL 9.0-13.0
D-LCR 29.7 fL 6.8-100
Examination The Results Unit Reference value

Calculate type
50.0-70.0
Netrophils %
L 20.80 25.0-40.0
Lymphocytes %
57.60 2-4
Eosotophils
H.12.10 % 0-1
Basophils
00.00 % 2-8
monocytes
21.10
Clinical chemistry mg/dL
70-160
Acc glucose mmol/l
73 135-155
Sodium Blood L 129.9 mmol/l 3,6-5.5
Potassium Blood 4.98 93-108
mmol/l
Chloride Blood 98,3
Analisys Data
No Data Etiology Problem
DS: Lose the liquid active Deficit electrolytes fluid
client said his body was hot,
stomachache,nausea and vomiting 2x
DO:
dry lips, skin turgor is bad,
Sign of vital:
BP: 100/60 mmHg
P:110/mnt
RR: 24x/mnt
T:39 C
 Nursing Diagnose
 Deficit electrolytes fluid related to lose the liquid active
Thankyou   