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Decolongon, Adrian John J.

BSN 2C
Case Scenario:
Dale, a seven month infant was brought to the emergency room by his mother due to vomiting and diarrhea for 3 days. Fever
developed 8 hours prior to consult. On assessment his temperature is 38.6 degrees Celsius, anterior fontanel is slightly depressed, with
sunken eyes and poor skin turgor. His weight is 13 lbs. Mother stated that he previously weighed 15 lbs.
Assessment Diagnosis Outcome Implementation Rationale Evaluation Discharge Plan
Criteria
Objective Data: - Fever related - Patient will - Give fever - Reduce body - After the M- Advise the
- Temp: 38.6° to vomiting and overcome medication and add temperature and implemented patient to take
diarrhea elevated semisolid and low- to gradually interventions, the medicines
- Anterior temperature, fiber foods to the diet return bowel the client was and vitamins
Fontanel is give normal movement to its able to alleviate recommended
slightly stool and normal state. irregular bowel by the doctor,
depressed eliminate movements and and use
vomiting. - Increase fluid intake - To replenish decrease its therapeutic
- Sunken eyes the depleted body methods as
fluid as a result temperature. appropriate.
- Poor skin of diarrhea and
turgor vomiting E- Advise the
parents to
- Weight: 13 lbs follow doctor’s
orders and to
Subjective Data: continue
- Vomiting & monitoring.
Diarrhea for 3
days T- Encourage
parents to keep
- Fever an eye out for
developed 8 any further
hours prior to complications
consult with their child.

H- Educate
Decolongon, Adrian John J.
BSN 2C
- Skin turgor as - Patient will - Increase fluid intake - To rehydrate - After parents about
a result of overcome body fluids and increasing his the doctor’s
dehydration dehydration and cure skin fluid intake, the orders and
regain his skin impairment. client was able possible
integrity to alleviate skin treatments.
impairment and
regain regular O – Counsel
body hydration. parents for
further
questions and
guide them on
their next visit.

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