PRELIMINARY REPORT

BASIC HUMAN NEEDS WITH NUTRITION NEEDS FULFILLMENT DISORDERS

Arranged by:

SEKAR AYUDYA DWI PUTRI M

NIM: P1337420618014

UNDERGRADUATE NURSING APPLIED SCIENCE

HEALTH POLYTECHNIC OF SEMARANG

2019
 I. PAGE TITLE : PRELIMINARY REPORT BASIC HUMAN NEED WITH
NUTRITION NEEDS FULFILLMENT DISORDERS

II. BASIC CONCEPTS

A. Anatomy and Physiology of Digestive System
The digestive tract consists of the mouth, esophagus, stomach, small
intestine, large intestine, rectum and anus.
1. Mouth
The function of the teeth is to destroy food at the beginning of the
digestive process. Chewing well can prevent scarring on the surface of the
digestive tract. After chewing, the tongue pushes the food lumps into the
pharynx, where food moves to the upper esophagus and then down into the
stomach.
2. Esophagus
The esophagus is a long tube. The upper third is composed of bony
muscles and the rest are slippery muscles. Its surface is covered in mucous
membranes which produce secrete mucoid that is useful for protection.
3. Stomach
Food clots enter the stomach, with the largest portion of the digestive
tract. The movement of food through the stomach and intestine is made
possible by the existence of peristaltic, is alternating contraction and
relaxation movements of the muscles that push the food substance in waves-
like movements. As food moves toward the pyloric spingter at the distal end of
the stomach, the peristalsis increases. Now flabby lumps of food have become
a substance called chyme. Chyme is pumped through the pylorus spingter into
the duodenum. The average time needed to empty the stomach after eating is 2
to 6 hours.
4. Small Intestine
Small intestine consists of duodenum, jejunum, and ileum whose
length is approximately 6 meters with a diameter of 2.5 cm. The large intestine
consists of the rectum, colon and rectum which then empties into the anus.
The length of the large intestine is about 1.5 meters with a diameter of about 6
cm. The intestine receives chime (semi-solid) food from the stomach to absorb
water, nutrients, potassium, bicarbonate and enzymes.
 Chyme moves because of intestinal peristalsis and will gather into
feces in the large intestine. From eating to reaching the rectum normally takes
12 hours. The colon movement is divided into 3 parts, namely, first houstral
shuffing is the mixing of chyme to help absorb water, the second is the
contraction of haustrl which is a movement to push water and semi-solid
material along the colon, thirdly the peristaltic movement is the forward
movement to the anus in the form of waves. Foods that have passed through
the small intestine: Chyme, will arrive at the rectum 4 days after swallowing,
the amount of chime that is absorbed is approximately 350 ml.
5. Large Intestine (Colon)
Adult colon, approximately 125-150 cm in length or 50-60 inches,
consists of: Cecum, which is directly related to the small intestine. The colon
consists of ascending, transverse, descending and sigmoid colon. Rectum, 10-
15 cm / 4-6 inch. The main functions of the large intestine (colon) are:
 Water and nutrient absorption
 Protection / protection by secreting mucus which will protect the intestinal
wall trauma by feces and bacterial activity.
 Delivering leftovers to the anus by contraction.
 External anal / anal / orifice

B. Definition of Nutrition
Nutrition is nutrients and another substances related to health and disease,
including the whole process in the human body to receive food or materials from
the environment and use these materials for important activities in the body and
remove waste.
Nutrition functions to form and maintain body tissues, regulate processes
in the body, as a source of energy, and to protect the body from disease. Thus, the
main function of nutrition (suitor & hunter, 1980) is to provide energy for bodily
activities, form skeletal structures and body tissues, and regulate various chemical
processes in the body.
Nutrition problems are closely related to food intake and body metabolism
and the factors that influence it. In general, factors affecting nutritional
requirements are physiological factors for basal metabolic needs,
 pathophysiological factors such as the presence of certain diseases that interfere
with digestion or increase nutritional requirements, socio-economic factors such
as the ability of individuals to fulfill the nutritional needs.
Nutrient is an element needed for bodily processes and functions. Nutrition
is organic and non-organic substances found in food and needed by the body to
function properly (Kozier, 2004).

C. Nutritional Components
1. Water
Water includes 60% - 70% of adult individual body weight and
80% of infant body weight (Potter & Perry, 1992). Adult individuals can
lose about 2-3 liters of fluid per day through sweat, urine and breathing.
Water has a big role for the body. Apart from being a major component of
cell constituents, water also plays a role in channeling food substances to
cells. The function of water for the body itself is to assist chemical
processes / reactions in the body and play a role in controlling body
temperature. There is no single organ that can function without water.
2. Carbohydrate
Carbohydrates are the main energy source. Every 1g of
carbohydrates produces 4 kcal. Carbohydrates stored in the liver and
muscles form glycogen in very small amounts. Glycogen is a synthesis of
glucose, a fraction of energy during rest or fasting. Excess energy in
carbohydrates in the form of fatty acids. Carbohydrate metabolism
contains 3 processes, namely:
 Catabolism of glycogen to glucose, carbon dioxide and water is called
glycogenolysis.
 Anabolism of glucose formed by glycogen is called glycogenesis.
 The change from amino acids and glycerol to glucose is called
gluconeogenesis.
3. Protein
The protein functions is to grow, maintain and replace body tissues.
Every 1g of protein produces 4 kcal. The simplest form of protein is amino
acids. Amino acids are stored in a network of hormones and enzymes.
 Essential amino acids cannot be synthesized in the body, but must be
obtained from food.
4. Fat
Fat is the biggest source of energy. Every 1 grams of fat will
produce 9 kcal. Lipids are fats that can freeze at certain room
temperatures, where the lipids consist of triglycerides and fatty acids. The
process of formation of fatty acids is called lipogenesis. Activities that
require energy include:
 Breathing, blood circulation, body temperature, etc.
 Mechanical activity by muscles.
 Brain and nerve activity.
 Chemical energy to build tissues, enzymes, and hormones.
 Digestive fluid secretion.
 Absorption of nutrients in the digestive tract.
 Expenditures of metabolism.

Factors that affect energy needs:

 Basal Metabolism is increased
 Body activity
 Age factor
 Ambient temperature
 Disease
5. Vitamin
Vitamins are organic compounds that cannot be made by the body
and are needed in large quantities as catalysts in metabolic processes.
Vitamins are generally classified into:
 Fat-soluble vitamins, namely: vitamin A, vitamin D, vitamin E,
vitamin K.
 Water-soluble vitamins, namely vitamin B and vitamin C.
6. Mineral
Minerals are categorized into 2:
 Macromineral, that is: a person needs every day an amount of more
than 100 mg. For example: calcium, phosphorus, sodium, potassium,
magnesium, chloride, and sulfur.
  Micromineral, namely: a person needs every day an amount of
approximately 100 mg. For example: iron, zinc, manganese, iodine,
cobalt, chromium, copper, and chloride.

D. Nutritional Needs According to the Level of Age Development

1. Infants
In infants, digestion and absorption are still simple until the age of
6 months. The calories needed are around 110-120 calories / kg / day.
Fluid needs around 140-160 ml / kg / day. Babies before the age of 6
months of suitable nutrition is breast milk.
2. Toddler and Pre School Children
The habits that need to be taught at this age include:
 Provision of food in various variations
 Limit sweet foods
 Eat a balanced diet.
 Serving food time regularly.
Calorie requirements for each age:
 1 year = 100 kcal / day
 3 years = 300-500 kcal / day
3. School (6-12 years old)
Age Protein Calcium Fe Vit. A Vit. B1 Vit. C
Calories
(Years) (Grams) (Grams) (mg) (U. I) (mg) (mg)
5-6 1400 40 0,50 6 2500 0,6 25
7-9 1600 50 0,75 7 2500 0,6 25
10 - 12 1900 60 0,75 8 2500 0,7 25
4. Teen
Very high calorie, protein, mineral and vitamin requirements are
related to the continued growth process. Increased body fat will cause
obesity so that it will cause stress on body image.
5. Early Adult (23-30 years old)
Nutrition needs in young adulthood, in addition to the maintenance
and repair process of the body rather than growth. Nutritional requirements
generally take precedence over type and quality over quantity.
6. Adult (31-45 years old)
Adulthood is a productive period, especially related to physical
activity. Nutrition needs at this time need to get great attention and must be
differentiated between levels of work.
Nutritional needs for adults based on occupational level:
Work State
Nutritional
Light Moderate Hard
Elements
Man Woman Man Woman Man Woman
Calories 2100 1750 2500 2100 3000 2500
Protein 60 55 65 65 70 70
Calcium 0,5 0,5 0,5 0,5 0,5 0,5
Ferum 8 10 8 8 10 8
Vit. A 2500 2500 2500 2500 2500 2500
Vit. B1 1 0,8 1,2 1 1,5 1,5
 III. PATHWAYS

Digestive tract Decreasing health Metabolic needs for

Lifestyle and habits
diseases status growth

gastric mucosal swallowed muscular unhealthy eating Increased nutrition

erosion weakness habits intake

swallowed muscular
weakness
decreased gastric swallowing excess unnecessary energy demand
unhealthy eating
tone and peristalsis disorders things in the body increases
habits

increased nutrition
nutritional intake is intake
get hungry easily
reflux duodenum to not fulfilled
absorption in the
the stomach
body is not perfect

weight loss
increased appetite
nausea
risk of nutritional imbalance:
more than the body needs
eat often
vomiting

weight gain
nutritional imbalance: less than the body's
needs

nutritional imbalance : more than the

body’s needs
IV. ASSESSMENT
A. PATIENT IDENTITY (Age, sex, occupation and education).
The patient's age can indicate the stage of development of the patient
both physically and psychologically, sex and occupation need to be examined
to determine the relationship and its influence on the occurrence of problems /
illnesses, and the level of education can affect the client's knowledge about the
problem / disease.

B. PATIENT ADMISSION
Patient admission is data or exactly when the patient entered the
hospital to undergo inpatient or outpatient care.

C. NURSING HISTORY
Nursing history is data collected about the level of client's welfare
(current and past), family history, changes in life patterns, socio-cultural
history, spiritual health, and mental and emotional reactions to illness.

D. HEAD TO TOE PHYSICAL EXAMINATION

Anthropometry
 Ideal Body Weight: (Height-100) ± 10%
 Wrist Circles
 Upper arm circumference (MAC / Mid Aid Circumstances)
 Normal value of women: 28.5 cm
 Normal male values: 28.3 cm
 Skin folds in the triceps muscle (TSP / Triceps Skin Fold)
 Normal value of women: 16.5-18 cm
 Normal male values: 12.5-16.5 cm
 Body mass index = Weight (kg) : Height (m2)

Biochemical (Laboratory)
 Albumin (Normal: 4-4.5 mg / 100ml)
 Transferrin (Normal: 170-250 mg / 100ml)
 Hemoglobin / Hb (Normal: 12 mg%)
 BUN (Normal: 10-20 mg / 100ml)
 Creatinine excretion for 24 hours (Normal: male: 0.6-13 mg / 100ml,
female: 0.5-1.0 mg / 100ml)

Clinical Sign
Disease History:
 A history of overweight or underweight
 Weight Loss and Height
 Experiencing certain diseases
 History of surgery in the gastrointestinal system
 Anorexia
 Nausea and vomiting
 Diarrhea
 Alcoholism
 Mental Disability
 Radiation therapy

Dietary History
 Impaired function of chewing and swallowing
 Inadequate food intake
 Incorrect or strict diet
 Lack of food supplies for 10 days or more
 Inadequate funds for food supply
 Inadequate food preparation facilities
 Lack of storage for groceries
 Physical disability
 Elderly who live and feed themselves

Assessment Area Normal Sign Abnormal Sign

Agile, energetic, able to apathetic, lethargic,
General appearance rest well
looking tired
Weight within the normal range obesity, underweight
according to age and
height
 Hair radiant, oily, and not dry dry, faded, reddish, thin,
dull branched
E. D Nail Pink, hard break easily, shaped like a
I spoon
A Eye clear, moist, pink pale, dry conjunctiva,
G conjunctiva there are signs of infection
N Lip moist, pink Dry, cracked, swollen,
O lesions, stomatitis, pale
S mucous membranes
T Gum Pink, moist bleeding, inflammation,
I shaped like a spoon
C Muscle chewy, well-developed weak, lack of tone, unable
to work
ECardiovascular system pulse and blood pressure pulse rate more than 100x
X are normal, heart rhythm / minute, abnormal
A is normal rhythm, low / high blood
M pressure
I Digestive system good appetite, normal and anorexia, constipation,
N regular elimination diarrhea, liver enlargement
A Nervous system normal reflexes, alert, confused, paresthesia,
T good attention, stable decreased reflexes
I emotions
O
N
1. Laboratory examination
2. Upper gastrointestinal endoscopy is the standard for the diagnosis of
GERD with the discovery of mucosal breaks in the esophagus (reflux
esophagitis). If no mucosal break is found in upper gastrointestinal
endoscopy in patients with typical symptoms of GERD, this
condition is called non-erosive reflux disease (NERD).
3. Rongent, is a detection device that is already familiar in the medical
world. But for ordinary people or who have never known this tool
usually hear immediately feel fear and worry. Though this tool is
needed to detect diseases or abnormalities suffered in our body.
 F. DATA ANALYSIS AND SYNTHESIS
According to the KBBI, analysis is an investigation of an event
(writing, deed, etc.) to find out the real situation. While synthesis is a mixture
(mixture) of various meanings or things so that it becomes a harmonious unity.

V. NURSING DIAGNOSIS FORMULATION (PROBLEM LIST)

A. Fluid volume deficiency is related to:
 Failure of regulatory mechanisms
 Lack of active fluid

B. An imbalance of nutrients less than the body's needs is related to:

 Inability to digest food
 Inability to absorb nutrients
 Lack of food intake
 Vomiting, anorexia, digestive disorders
VI. PLANNING
Purpose and Expected
No Nursing Diagnose Intervention
Result
1.Lack of fluid volume NOC: NIC:
 Fluid balance Fluid management
Definition : decrease in  Hydration  Maintain accurate
intravascular, interstitial, and /  Nutritional Status: intake and output
Food and Fluid records
or intracellular fluid. This Intakes  Monitor hydration
refers to dehydration, fluid loss  Nausea and status (mucous
vomiting control membrane moisture,
alone without changes in adequate pulse,
sodium levels. Results Criteria: orthostatic blood
 Maintain urine pressure), if needed
output according to  Monitor lab results
Limitation of characteristics: age and body according to fluid
 Thirsty weight, normal urine retention (BUN, Hmt,
BJ, normal HT urine osmolality)
 Weaknesses
 Blood pressure,  Vital sign monitor
 Dry skin
pulse, body  Monitor food / fluid
 Dry mucous membranes
temperature are intake and calculate
 Increased pulse frequency
within normal limits daily calorie intake
 Increased hematocrit
 There are no signs of  Fluid collaboration IV
 Increased urine
dehydration, good  Monitor nutritional
concentration
skin turgor elasticity, status
 Increase in body moist mucous  Give liquid
temperature membrane, no  Give diuretics
 Sudden weight loss excessive thirst, according to
 Decreased urine output CRT normal. instructions
 Decreased venous filling  Nausea and  Give IV fluids at
 Decreased blood pressure room temperature
 Decreased pulse pressure vomiting can be
 Push oral input
 Decreased skin turgor overcome  Give nasogastric
 Decreased tongue turgor replacement
 Decrease in pulse volume according to the
 Change in mental status output
 Encourage the family
to help patients eat
Related factors:  Offer snacks (fruit
 Failure of regulatory juice, fresh fruit)
mechanisms  Collaborate doctor if
 Loss of active fluid signs of excess fluid
appear / worsen
 Set the possibility of
transfusion
Nausea management
 Assess for nausea
related to frequency,
duration, severity and
triggers for nausea
 Nonverbal
observation of
discomfort
 Assess the dietary
history of food, likes,
dislikes, and eating
culture
 Identification of drug-
related factors and
procedures that may
cause nausea.
 Collaborative
administration of
antiemetic drugs to
prevent nausea.
 Control
environmental factors
that might trigger
nausea (sound or light
stimulation.
 Reduce and avoid
personal factors that
might trigger nausea
(fear, anxiety,
fatigue).
 Identify successful
strategies for
managing nausea.
 Promote adequate rest
and sleep to reduce
nausea.
 Eat small but frequent
portions
 Encourage eating high
in carbohydrates and
low in fat.
 Monitor the adequacy
of nutrients and
calories.
2. Nutritional imbalances: less
than the body's needs
Definition: nutrient intake is
not enough to meet metabolic
needs.
Limitation of Characteristics:
 Weight 20% or more below
the ideal body weight range
 Hyperactive bowel sounds
 Full soon after eating
 Diarrhea
 Disorders of taste sensation
 Excessive hair loss
 Chewing muscle weakness
 Muscle weakness to
swallow
 Capillary fragility
 Misinformation
 Misperception
 Inability to eat food
 Abdominal cramps
 Less information
 Lack of interest in food
 Pale mucous membranes
 Abdominal pain
 Weight loss with adequate
food intake
 Oral thrush
 Decreased muscle tone
Related factors:
 Biological factors
 Economic factors
 Psychosocial disorders
 Inability to eat
 Inability to digest food
 Inability to absorb nutrients
 Lack of food intake
NOC NIC
 Nutritional Status:Nutrition management
Food and Fluid  Assess for food
Intakes allergies
 Collaboration with
Results Criteria: nutritionists to
 An increase in body determine the number
weight in of calories and
accordance with the nutrients needed by
objectives patients
 Ideal body weight  Instruct the patient to
according to height increase Fe intake
 Able to identify  Instruct the patient to
increase protein and
nutritional needs
vitamin C
 Give sugar substance
 Make sure the diet
you eat contains high
fiber to prevent
constipation
 Give selected food
 Teach patients how to
make daily food
records
 Monitor the amount
of nutrition and
calorie content
 Provide information
about nutritional
needs
Nutrition monitoring
 BB patients are within
normal limits
 Monitor for weight
loss
 Monitor the type and
amount of activity
that is normally done
 Monitor the
environment during
meals
 Monitor dry skin and
pigmentation changes
 Monitor skin turgor
 Monitor dryness, dull
hair, break easily
 Monitor nausea and
vomiting
 Monitor favorite
foods
 Monitor growth and
development
 Monitor pale, reddish,
and dry conjunctival
tissue
 Monitor calorie and
nutrient intake
 Note the presence of
edema, hyperemic,
hypertonic papillae of
the tongue and oral
cavity
VII. REFERENCES
 Docterman dan Bullechek. Nursing Invention Classifications (NIC), Edition 6,
United States Of America: Mosby Elseveir Acadamic Press, 2013.
 Maas, Morhead, Jhonson dan Swanson. Nursing Out Comes (NOC), United States
Of America: Mosby Elseveir Acadamic Press, 2013.
 Nanda International (2018). Diagnosis Keperawatan: definisi & Klasifikasi. 2018-
2020. Penerbit buku kedokteran EGC : Jakarta
 Potter & Perry. 2006. Fundamental Keperawatan. EGC: Jakarta.