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Home Nursing Diagnosis Gastroenteritis nursing care

NURSING DIAGNOSIS

Gastroenteritis nursing care

Gastroenteritis nursing care
Gastroenteritis
1. Definition
Gastroenteritis (GE) is an inflammation of the stomach and intestines that give the
symptoms of diarrhea with or without vomiting (Sowden, et all.1996).
Gastroenteritis is defined as bowel movements that are not normal or watery stools form
with more frequency than usual (FKUI, 1965).
Gastroenteritis is an inflammation of the stomach and intestinal area caused by various
bacterial, viral and parasitic pathogens (Whaley & Wong's, 1995).
Gastroenteritis is kondisis with the characteristics of vomiting and diarrhea caused by
infection, allergy or poisoning of food substances (Marlenan Mayers, 1995).
Of the four above understanding can the authors conclude that Gstroentritis is an
inflammation of the stomach and intestines that provide diarrhea symptoms with more
frequency than is usually caused by bacterial, viral and parasitic pathogens.
2. Etiology
The cause of acute diarrhea include:
Factors Infections
Virus Infection
Retavirus
The most common cause of acute diarrhea in infants, often didahulu or accompanied by
vomiting.
Arise throughout the year, but usually in winter.
Can be found fever or vomiting.
Get a decrease in HCC.
Enterovirus
Usually occur in summer.

Adenovirus
Arise throughout the year.
Cause symptoms in the digestive tract / respiratory.
Norwalk
Epidemic
Can heal itself (within 24-48 hours).
Bacteria
Stigella
Seasonal, peak in July-September
Incidence highest in the age 1-5 years
Can be associated with febrile seizures.
Vomiting is not prominent
Tues plain in feces
Stem cells in the blood
Salmonella
All ages but higher under the age of 1 year.
Penetrate the intestinal wall, bloody stools, mukoid.
There may be a temperature increase
Vomiting does not protrude
Tues plain in feces
The incubation period of 6-40 hours, duration 2-5 days.
The organism can be found in the feces for months.
Escherichia coli
Whether that penetrate the mucosa (bloody stools) or which produce entenoksin.
Patients (usually babies) can look very sick.
Campylobacter
Its invasis (bloody stool and mucus mixed) in infants can cause bloody diarrhea without
other clinical manifestations.
Severe abdominal cramps.
Vomiting / dehydration is rare
Yersinia Enterecolitica
Mucous stool
Often found innocent cells in the stool.
There may be severe abdominal pain
Diarrhea for 1-2 weeks.
Often resembling apendicitis.
Non Infeksiosus Factor
Malabsorption
Disaccharide carbohydrate malabsorption (intolerance, lactose, maltose, and sucrose), nonsaccharide (glucose intolerance, fruktusa and galactose). In infants and children the most
important and most common is lactose intolerance.
Fat malabsorption: long chain triglycerides.
Malabsorption of proteins: amino acids, B-laktoglobulin.
Food factor
Spoiled food, toxic, food allergies (milk alergy, food alergy, dow'n senditive milk protein

enteropathy / CMPSE).
Psychological Factors
Fear, anxiety.
3. Pathophysiology
The cause of acute gastroenteritis is a viral entry (Rotravirus, enteris adenovirus, Norwalk
virus), bacteria or toxins (Compylobacter, Salmonella, Escherihia coli, Yersinia and others),
parasites (Biardia Lambia, Cryptosporidium). Some of these pathogenic microorganisms
causing infection in cells, produce enterotoxin or Cytotoksin which damage cells, or attached
to the intestinal wall in acute gastroenteritis.
Transmission of Gastroenteritis bias through the faecal-oral route from one patient to
another.Several cases of the spread of pathogens encountered due to contaminated food
and beverages.
The basic mechanism is a disorder causing osmotic diarrhea (food that can not be absorbed
will cause osmotic pressure in the cavity of the intestine increased resulting in a shift of
water and electrolytes into the intestinal cavity, the contents of the gut cavity, causing
excessive diarrhea). In addition, disruption due to toxin secretion in the intestinal wall, so
that water and electrolyte secretion increases then occur diarrhea. Disorders that cause
intestinal multilitas hiperperistaltik and hipoperistaltik. As a result of diarrhea itself is losing
water and electrolytes (dehydration) that lead to acid-base disturbance (metabolic acidosis
and hypokalemia), impaired nutrition (intake less, the output is excessive), hypoglycemia
and blood circulation disorders.
4. Clinical Manifestation
Abdominal pain (abdominal discomfort)
The pain in gut
Nausea, sometimes vomiting
Decreased appetite
A sense of satiety soon
Flatulence
Burning sensation in the chest and abdomen
Regurgitation (out of fluid from the stomach of a sudden).
5. Complication
Dehydration
Hypovolemic shock
Convulsions
Bacteremia
Mal nutrition
Hypoglycemia
Intolerance secondary to intestinal mucosal damage.
6. Dehydration degree level
Mild dehydration
Loss of fluid 2-5% of body weight with the clinical picture is less elastic skin turgor,

hoarseness, the patient has not fallen on the state of shock.

Moderate Dehydration
Loss of fluid 5-8% of body weight with poor skin turgor clinical picture, hoarseness, people
with pre-shock pulse falling fast and deep.
Dehydration Weight
Loss of fluid 80-10% of bedrat body with such clinical signs of dehydration is coupled with
decreased consciousness, apathy to coma, stiff muscles until cyanosis.
7. Examination Support
Laboratory tests include:
Feces examination
Macroscopic and microscopic.
pH and sugar content in feces with litmus paper and tablets dinistest, if there is suspected
glucose intolerance.
If necessary, perform the examination culture and resistance testing.
Blood Examination
blood pH and reserve multiplied and electrolytes (sodium, potassium, calcium and
phosphorus) in serum to determine the Asama-base balance.
Levels of urea and kreatmin to determine kidney function.
Doudenal Intubation
To know the micro-organism or parasite qualitatively and quantitatively, especially done in
patients with chronic diarrhea.
8. Medical Treatment
Giving fluids.
Diatetik: provision of food and special drinks on patients with the aim of healing and
maintaining health as for things to note: Provide food that contains calories, protein,
vitamins, minerals and food clean.
Drugs.
Nursing in Patients with gastroenteritis
A. Assessment
Systematic assessment includes data collection, data analysis and problem
determination. The collection of data obtained by means of intervention, observation, psikal
assessment.
Assessment of data by Cyndi Smith Greenberg, 1992 are:
The identity of the client.
History of nursing.
Prefix attack: Originally whiny child, anxiety, increased body temperature, anorexia and
diarrhea occur.
The main complaint: the more liquid Faeces, vomit, if losing a lot of water and electrolytes

occur symptoms of dehydration, body weight decreased. In infants sunken fontanel large,
tone and reduced skin turgor, mucous membranes of the mouth and lips dry, CHAPTER
frequency more than 4 times with watery consistency.
Past medical history.
History of the illness, history of immunization.
Family psychosocial history.
Treated will be a stressor for the child itself and for the family, the anxiety increases if the
parents do not know the procedure and treatment of children, after realizing her illness, they
will react with anger and guilt.
Basic needs.
The pattern of elimination: will change the BAB more than 4 times a day, BAK few or rare.
Nutritional pattern: beginning with nausea, vomiting, anopreksia, causing weight loss
patients.
The pattern of sleep and rest will be disturbed because of abdominal distension that would
cause discomfort.
Pattern hygiene: bathing habits every day.
Activities: will be disturbed because the body is very lamah and the pain due to abdominal
distension.
Physical examination.
Psychological examination: general condition seemed weak, kesadran composmentis to
coma, high body temperature, rapid and weak pulse, breathing rather quickly.
Systematic examination:
Inspection: sunken eyes, large fontanel, mucous membranes, mouth and dry lips, weight
loss, anal redness.
Percussion: presence of abdominal distension.
Palpation: less elastic skin turgor.
Auscultation: bowel sounds hearing.
Examination tinglkat growth and development.
Diarrhea in children will experience disruption due to child dehydration so that body weight
decreased.
Investigations.
Stool examination, complete blood and doodenum intubation is to find the cause of the
quantitative and qualitative.

B Nursing Diagnosis
Volume of fluid and electrolyte deficit is less than body requirements related to excessive

fluid output.
Impaired nutritional needs less than the body needs berhubuingan with nausea and
vomiting.
Impaired skin integrity related to the irritation, the frequency of excessive CHAPTER.
Impaired sense of comfort pain associated with abdominal distension.
Lack of knowledge related to the lack of information about illness, prognosis and treatment.
Anxiety associated with separation from parents, a scary procedure.

C. Intervention
Diagnosis 1.
Volume of fluid and electrolyte deficit is less than body requirements related to excessive
fluid output.
Objectives:
Devisit fluid and electrolyte resolved
Criteria results:
Signs of dehydration are not available, oral mucosa and lips moist, well-balanced fluid balan
Intervention
Observation of vital signs. Observation for signs of dehydration. Measure infut and output of
fluid (balanc ccairan). Provide and encourage families to provide drinking a lot less than
2000 - 2500 cc per day. Collaboration with physicians in providing therafi fluid, electrolyte
lab examination. Collaboration with the nutrition team in the provision of low-sodium fluids.
Diagnosis 2.
Impaired nutritional needs less than the body needs berhubuingan with nausea and
vomiting.
Objectives:
Impaired nutritional needs resolved
Criteria results:
Clients increased nutritional intake, diet out 1 portion of which is provided, nausea, vomiting
does not exist.
Intervention:
Assess client's nutritional patterns and changes that occur. Weigh weight loss clients. Assess
the factors causing the fulfillment of nutritional disorders. Perform physical examination of
the abdomen (palpation, percussion, and auscultation). Give a warm conditions and diet in
small portions but frequently. Collaboration with a team of nutrition in determining the
client's diet.
Diagnosis 3.
Impaired skin integrity related to the irritation, the frequency of excessive CHAPTER.

Objectives:
Impaired skin integrity resolved
Criteria results:
Skin integrity returns to normal, no irritation, signs of infection does not exist
Intervention:
Replace the child if the diaper is wet. Clean the buttocks slowly soap non alcohol. Give zalp
such as zinc oxsida if there is irritation of the skin. Observation of the buttocks and perineum
of infection. Collaboration with physicians in providing therafi antipungi as indicated.
Diagnosis 4.
Impaired sense of comfort pain associated with abdominal distension.
Objectives:
Pain can be resolved
Criteria results:
Pain can be reduced / hiilang, calm facial expression
Intervention:
Observation of vital signs. Assess the level of pain. Set a comfortable position for the
client.Give a warm compress on the area abdoment. Collaboration with physicians in
providing therafi analgesics as indicated.
Diagnosis 5.
Lack of knowledge related to the lack of information about illness, prognosis and treatment.
Objectives:
Increasing family knowledge
Criteria results:
Client families with the disease process client horrible, calm facial expression, many families
are not asked again about the client's disease process.
Intervention:
Assess client's level of family education. Assess the level family knowledge about the
disease process client. Explain about the disease process with the client through
penkes. Provide opportunities for families when there is not incomprehensible. Involve
families in the provision of action on the client.
Diagnosis 6.
Anxiety associated with separation from parents, a scary procedure.
Objectives:
The client will show decreased levels of anxiety
Intervention:
Assess the client's anxiety level. Kaji trigger anxiety. Create a schedule of contacts with
clients. Assess the desirability of the client. Give your favorite toy as a client. Involve
families in every action. Encourage the family unrtuk always accompany clients.

D. Evaluation
The volume of fluid and electrolytes returned to normal as needed.
Nutritional needs are met in accordance kebutuhantubuh.
Skin integrity back noprmal.
Sense of comfort are met.
Knowledge ancestry increases.
Anxious in client is resolved.
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