NURSING CARE PLAN

Assessment Nursing Planning Nursing Intervention Rationale Evaluation

Diagnosis

Subjective Data: Fluid volume Short Term: Independent Goal Met

deficit related After 2 hours of  Secure the patient’s  To procced with the Short Term:
“Nagsusuka at to active fluid nursing consent treatment and ensure After 2 hours of
nagtatae ako” prior to volume loss as intervention the the patient and nurse nursing intervention
admit as verbalized evidenced by patient will able to protection for ethical the patient was able
by the patient. watery stool maintain fluid and legal purposes. to maintain fluid
and vomiting. volume as a volume as a
functional level. functional level.
Objective Data:  Establish rapport
 To promote the
(+) Vomiting Long Term: patient’s cooperation Long Term:
(+) Watery stool After 8 hours of After 8 hours of
nursing nursing intervention
Vital Signs: intervention the  Monitor the patient’s  To monitor any the patient was able
patient will able to; vital sign alterations and to;
BP: 90/60 establish baseline
 Demonstrate data.  Demonstrate
HR: 70 lifestyle lifestyle changes
RR: 20 changes to to prevent the
prevent the  Assess the patient’s  To determine the development of
Temp: 36.7° C development of hydration habits right approach if the fluid volume
fluid volume patient has potential deficit.
O2 Sat: 100% deficit. dehydration.
 Verbalized an
 Verbalize an  Assess the patient’s  To monitor the awareness
awareness skin and oral mucous patient’s hydration regarding to
regarding to membrane
causative factors
causative and appropriate
factors and  Encourage the patient  To promote hydration interventions.
appropriate to increase fluid and prevent
interventions. intake dehydration.

 Discuss individual  To reduce risk for

risk factors, potential injuries and
problems and dehydration.
interventions
regarding to the
disease of the patient.

 Monitor the patient’s

fluid intake  To prevent
dehydration and
overhydration

Dependent:

 Administer
 To treat vomiting,
medications such as
diarrhea and
metoclopramide and
ceftriaxone through suspected bacterial
IV as ordered. infection as well as to
prevent dehydration.

 Administer zinc  To reduce the

orally as ordered. complications due to
the presence of
diarrhea and
 vomiting.

 Administer probiotics
as ordered.  To improve gut health
including the bowel
regularity and
digestion as well as to
reduce discomfort.

 Administer oral
rehydration solution  To replace water and
as ordered. electrolytes loss due
to diarrhea and
vomiting

 Hook D5LRS RD
 To maintain body
300 cc as ordered.
fluids and nutrition as
well as for
rehydration.
 Assessment Nursing Planning Nursing Intervention Rationale Evaluation
Diagnosis

Subjective Data: Hyperthermia Short Term: Independent: Goal Met

“Nilagnat ako” as related to impaired
verbalized by the health status as After 2 hours of  Establish rapport  To promote a nurse- Short Term:
patient. evidenced by an nursing patient interaction
increase of intervention the and establish trust After 2 hours of
temperature with patient will able and cooperation on nursing intervention
Objective Data: to; the patient. the patient was able
38.5 ° C
to;
- Skin is warm to Maintain a body  Assess the patient’s  To monitor medical
touch temperature from vital signs problem and establish Maintain a body
38.5 ° C to 36.5 - baseline data of the temperature from
37.5 ° C. patient. 38.5 ° C to 37.1 ° C
Vital Sign:
 Monitor the  To detect if the
BP: 110/70 Long Term: patient’s body treatment is working. Long Term:
temperature.
HR: 80 After 6 hours of After 6 hours of
RR: 20 bpm/min intervention the  Instruct the patient  To reduce metabolic intervention the
patient’s altered to maintain bedrest. demands and oxygen patient’s altered body
Temp: 38.5° C body temperature consumption. temperature was
will be eliminated.
O2 Sat: 99% eliminated.  Advice the patient’s  To decrease the
guardian for Tepic patient’s body
Sponge Bath (TSB). temperature by
increasing the control
of body temperature
through evaporation
and conduction.
 Advice the patient  To promote heat loss
to wear loose through radiation and
clothes. conduction.

 To regulate the
 Monitor and adjust patient’s body
room temperature. temperature.

Dependent:
 To reduce the
 Administer patient’s body
antipyretic temperature.
medications such as
Paracetamol
through IV as
ordered.
 To prevent
 Increase OFI as dehydration and
ordered. restore fluid loss and
electrolyte due to
diarrhea and
vomiting.
 Assessment Nursing Planning Nursing Intervention Rationale Evaluation
Diagnosis

Subjective Data: Dysfunctional Short Term: Independent: Goal Met

“Sumakit ang tyan Gastrointestinal Short Term:
ko pagkatapos ko Motility related to After 1 hour of  Establish rapport  To establish trust and
kumain ng isda” unsanitary food nursing cooperation and to After 1 hour of
prior to admit as preparation as intervention the promote a nurse- nursing intervention
verbalized by the evidenced by patient will able patient interaction. the patient was able
patient. abdominal pain to; to;
and vomiting.  Assess the patient’s  To establish baseline
 Verbalize vital signs data and monitor any  Verbalized
Objective Data: understanding complications. understanding of
- Vomiting of causative causative factors
- Abdominal pain factors  Assess for  To identify serious regarding to
regarding to characteristics of conditions unsanitary food
unsanitary abdominal pain. preparation.
food
preparation.  Inspect the abdomen  To monitor any
 Demonstrate
and note for contour. presence of
appropriate
 Demonstrate distension
appropriate behaviors related
behaviors  Auscultate the  To assess for to right sanitary
related to abdomen intestinal function. food preparation.
right sanitary
food  Palpate abdomen  To note masses,
preparation. enlarge organs,
Long Term:
elicitation of pain
with touch and
After 3 hours of
Long Term: pulsation of aorta.
intervention the
patient was able to;
After 3 hours of  Maintain  To reduce intestinal
intervention the bloating and risk for  Verbalize
gastrointestinal rest
patient will able vomiting. relieved from
to; abdominal pain
 Encourage the patient  To monitor any and vomiting.
 Verbalize to report any changes indications of severe
relieve from in nature and condition.
abdominal intensity of pain.
pain and
vomiting. Dependent:

 Administer  To improve
medications such as gastrointestinal
Omeprazole, motility, control
metronidazole and vomiting, alleviate
metoclopramide as abdominal pain and
ordered. discomfort, and to
treat and prevent
gastrointestinal
complications.
 Increase OFI  To replace fluid and
electrolyte loss and
prevent dehydration.