NURSING CARE PLAN

Assessment Nursing Background Nursing Goal & Nursing Rationale Evaluation

Diagnosis Knowledge Objectives Intervention
Situational
“Nagtatae at Fluid Volume Immediate Cause: At the end of 8 hour Goals met by the
Nagsusuka” as Deficit r/t active Active fluid loss shift the patient will end of the shift the
verbalized by the volume loss (active (prolonged loose, be able to maintain patient maintain
patient fluid unformed stool and fluid volume at a fluid volume at a
loss(prolonged vomiting), as functional level as functional level as
loose, unformed evidenced by: evidenced by stable evidenced by stable
- Weak in stool and vital signs (PR), vital signs (PR),
Appearance vomiting), as Intermediate moist mucus moist mucus
- (+) Vomiting evidenced by: Cause: Bacterial/ membranes, good membranes, good
- Rashes noted at viral process skin turgor and skin turgor and
the back prompt capillary prompt capillary
Vital Signs: Primary Cause: refill refill.
BP: 100/80 Contaminated food
PR: 87 bpm and water. Objectives:
RR: 22 cpm After nurse –
Temp.: 37°C Health patient interaction,
Implications: the patient will be
able to:
Complications of
diarrhea of the 1. Manifest stable Independent: Effectiveness:
diarrhea include the vital signs Monitor vital Tachycardia is The patient was
potential for signs present along with a able to manifest
cardiac varying degree of stable vital signs.
dysrhythmias fluid deficit. Fever
because of increases
significant fluid metabolism and
and electrolyte loss exacerbates fluid
loss.
(especially loss of 2. Maintain accurate a. Monitor intake Fluid replacement Effectiveness:
potassium) Urinary intake and output. and output needs are based on The patient was
output of less than correction of current able to maintain
30 ml per hour for deficits and ongoing accurate intake and
2 to 3 consecutive losses. output.
hours muscle
weakness
paresthesia, 3. Receive a. Provide oral To replace the fluid Effectiveness:
hypotension, appropriate fluid rehydration losses and prevent The patient was
anorexia, replacement therapy frequently further complication able to receive
drowsiness with a in small amounts. like severe appropriate fluid
low potassium level dehydration. replacement.
Decrease potassium
levels cause cardiac
dsyrhythmias that b. Replace To prevent
can lead to death. electrolytes as metabolic
ordered imbalance
and
(medical – surgical acidosis
nursing, Brunner &
Suddarth’s, 10th
edition, Vol.1, p. 4. Manifest moist Provide frequent To prevent injury Effectiveness:
1032) mucus membranes oral care from dryness The patient was
able to manifest
Excessive fluid loss moist mucus
can lead to membranes
hypovolemic shock

(medical – surgical 5. Manifest good Encourage To maintain skin Effectiveness:

nursing, Brunner & skin turgor relatives of the integrity and The patient was
Suddarth’s, 10th patient to provide prevent excessive able to manifest
edition, Vol. 2, p. bath less dryness good skin turgor
2131 frequently using
mild cleanser/soap
and provide
 optimal skin care
with suitable
emollients

6. Remain Turn frequently, Tissues are Effectiveness:

comfortable massage skin, and susceptible to The patient was
protect bony breakdown because able to remain
prominences of vasoconstriction comfortable
and increased
cellular fragility

Dependent: Effectiveness:
7. Receive a. Establish 24 – Prevents peaks/ The patient was
appropriate hour fluid valleys in fluid level able to receive
pharmacologic replacement needs appropriate
treatment and routes pharmacologic
treatment

b. Administer IV To replace fluid Appropriateness:

fluids as indicated losses The intervention
were appropriate to
the patients
condition

Acceptability:
The interventions
were accepted by
the patient and her
relatives
 Adequacy:
The manpower,
materials and
money were
adequate to meet
the goal and
objectives.

NAME: HILARIO, LANI

AGE: 17 years old
DIAGNOSIS: ACUTE GASTRO ENTERITIS

BALAMBAN, KRISHIEL E. MR. ARNEL LIM, M.D.

BSN III, BLOCK 2 (CLINICAL INSTRUCTOR)
ARELLANO UNIVERSITY – PASAY