on March 14 2019 at 09.00 WIB, Ny.

S 22th came from the Abdul Moeloek Hospital with

complaints of diarrhea for 2 days. She said cramp and pain in the abdomen. the consistency
defecated watery mucus with a frequency of 5-6 times every day. According to the results of
observations by nurses, the client's body is hot, the color and smell of the faeces are typical.
After being asked again the client said before eating spicy food.

Vital Sign: 110/70 mmHg, Pulse: 84 x / minute, RR: 20x / minute, Temperature: 38º C
General condition: Weak, less elastic skin turgor and dry mucosa lip

1. Assessment Of Nursing Data

No. Register: 20

Room: Rose 1

Date / time : 14 March 2019, 09.00

Date of assessment: 14 March 2019

Medical diagnosis: Diarrhea

2. IDENTITY
a. Biodata Client
Name : Ny.S
Gender : Female
Age : 22 years
Religion : Islam
Tribe : Java / Indonesia E
Ducation : High School
Job : student
Address : Bandar Lampung

b. Person in Charge
Name : Mr.y
Sex : Male
Age : 55 years
Religion : Islam
Tribe: Java / Indonesia
Education : senior high school
Occupation : teacher
Address : Bandar Lampung
3. History Of Health
a. Main Complaint
Client complained that frequency of his defecated 5-6 times a day

b. Present Health History

Client Complaint that he had diarrhea for 2 days ago from March 12 2019. The
client defecated deficiently, with a frequency of 5-6 times a day (± 300cc), stool
color and smell. The client stated before consuming spicy food. The client also
says his body is hot.

c. Past Health History

The client said never got sick like this. Client never take care of hospital.

d. History Health’s Family

The client said there were no family members who had DM, hypertension, and
other diseases.

4. Daily Activities
a. Elimination
At home : client said that defecate 5-6 times a day with the consistency of watery.
Client urine 2 – 6 times a day with yellow, there’s no difficulty in urinating.

In hospital : client said thatduring the hospital, client defecate 6 times a day with
the consistency still of watery. there’s no difficulty in urinating.

b. Nutrition
At home : rarely eat, it just 1-2 times a day. Client said that she loves the spicy
food. Client drinks 5-6glasses daily.
In hospital : client said in the morning, she only ate porridge up ¼ servings because
she feel sick and vomite every she want to eat. Client drinks only 4 to 5 glasses of
water

5. Physical Examination
a. Head
Head was normocephalic and had a smooth skull contour, her hair was smooth. and
was evenly distributed. The hair was brown color. No swellmg or tendemess noted
upon palpation.
b. Ears
Both ears were symmetrical; No discharges. No ulceration or lesion noted on the
area.
c. Eyes
Both eyes were sycmmetrical. Eyelashes equally distributed, the pupil was brown
color with pinkish conjunctiva.
d. Nose
 The external was symmetrical. Nasal flaring noted. air felt when exhaled. Nasal
mucosa was intact and pinkish in color and was free ot purulent discharges.
e. Mouth and throat
The lips were dry and pale-looking. Her teeth were still intact. Tonsils wete
uninnammed.
f. Neck
The neck was symmetrical and was proportion to head and shoulder. There’s no
thyroid.

Five sense. 1. Sense of sight

Patient can read normally. In the absence of snellen‘ chart. functional vision was

test: she can follow a hand movement with a 3-4 feel distance. She can recogntze person and
things.

2. Sense of taste

By offering different kind of food like candy. vinegar. mpalaya, and salt

patiem‘s taste buds can identify sweet. sour. bitter. and salty food. 3. Sense of smell

Patient has good smelling ability; she can distinguish different odors such as

fragrance or perfume and aroma of beverages that she dinks. 4. Sense of hearing

She can recognize sounds and could hear clearly. she responds to conversation

nonnally. She becomes alert when someone will open the door. She can hear the distance
particularly when someone enters the room.