F.

NCP PROPER

CUES EXPLANATION OF GOALS AND INTERVENTIONS RATIONALE EVALUATION ACTUAL

THE PROBLEM OBJECTIVES EVALUATION

S: Kumain kasi ako Diarrhoea is a state GOAL: Patient will Dx: Fully Met: Fully Met
ng lugaw sa isang in which an be free from Independent: If after 8 hours of Patient was
karinderya nung individual diarrhoea >Assess for >These assessment nursing compliant to health
nagbiyahe kaming experiences or is at abdominal findings are usually interventions, the teachings given.
papuntang Baguio risk of experiencing STO: discomfort, pain, linked with patient will gain
at simula noon, frequent passages After 8 hours of cramping, diarrhoea, to have knowledge about
biglang of liquid stool or nursing frequency, urgency, baseline data. diarrhoea through
nakaramdam ako ng unformed stool. interventions, loose or liquid verbalization of
pananasakit sa tiyan Presence of patient will gain stools, and understanding of
at nagtatae na ako infectious agents knowledge about hyperactive bowel the causative factor,
as verbalized by the in the body diarrhoea through sensations. rationale for the
patient. verbalization of >Evaluate Pattern of >Assessment of treatment regimen.
|
understanding of defecation. defecation pattern
O: Microorganisms the causative factor, will help direct Partially Met:
>Loosed bowel attach and enter rationale for the treatment. If after 8 hours of
movement with mature treatment regimen. nursing
yellowish watery enterocytes at the >Assess hydration interventions, the
stool minimum of tips of small LTO: status including: patient will have
3x a day intestinal villi After 3 days of *input and output >Diarrhoea can lead difficulty in
>Increased bowel | nursing to profound understanding the
sounds and interventions, dehydration health teachings
Structural
peristalsis patient will be free *moisture of >Dehydration given.
>Nausea/ Vomiting changes to small from diarrhea as mucous membranes causes dry mucous
>Abdominal bowel mucosa manifested by membranes. Not Met:
Cramping | adequate and *skin turgor >Decreased skin If after 8 hours of
>poor skin turgor Inflammation of normal intake and turgor and tenting nursing
>sunken eyes lamina propria output, reduction in of the skin occur in interventions, the
>dry mucous | the frequency of dehydration. patient will have
membranes Bacteria releases stools. difficulty in
>Auscultate the >For presence, understanding the
endotoxin
Nsg. Dx.: Diarrhoea abdomen location and health teachings
related to infectious | characteristics of given and the
process Increased amount bowel patient shows non-
movement/sounds.
 of diarrheal fluid compliance to
| >Check diagnostic >To know the health teachings.
Active secretion results changes in the
Dependent: patients condition
of chloride and
>Administer anti-
bicarbonate ions
diarrheal >For the treatment
|
medication as of infectious
inhibition of ordered. process, decrease
sodium and >Regulate IVF as motility and
water ordered. minimize fluid loss.
|
After colonization, Tx:
enteric pathogens >Administer anti- >For the treatment
adhere or invade diarrheal of infectious
epithelium medication as process, decrease
| ordered. motility and
Production of minimize fluid loss.
enterotoxins or
cytotoxins Edx:
| Instruct patient on
Trigger release of the following:
cytokines attracting >Increase fluid >For hydration
inflammatory cells intake atleast 3
which contribute to L/day as tolerated
activated secretion >Avoid eating spicy, >Avoid increase in
| fatty or high- intestinal osmotic
Release of carbohydrate foods; pressure and
prostaglandins caffeine; sugar-free increased
| foods with sorbitol. peristalsis.
Signs and >Proper food >Avoid food
symptopms include: preparation contamination.
Fever, >Medication >Avoid bacterial
nausea/vomiting, Regimen resistance to
abdominal medications.
pain/cramping, >Proper >Avoid cross-
increased bowel handwashing before contamination.
sound/ peristalsis, and after eating and
loose bowel after going to the
movement. bathroom.
S: Nauuhaw ako at The state in which Goal: Patient will Independent: Fully Met: Fully Met
minsan wala akong an individual, who is consume daily >Monitor input and >Help initiate If after 8 hours of Patient was
ganang kumain as not NPO, nutritional output of patient nursing actions and nursing compliant to health
verbalized by the experiences or is at requirements in subsequent interventions, the teachings given.
patient. risk for inadequate accordance with her treatments, patient will gain
intake or activity level and determin the knowledge about
O: metabolism of metabolic needs. amount of food that importance of good
>Poor skin turgor nutrients for is consumed and nutrition through
>Dry mucous metabolic needs STO: After 8 hours eliminated by verbalization of
membranes with or without of nursing patient. understanding of
>Inadequate input weight loss. interventions, the consumption of
and output patient will daily nutritional
>sunken eyes verbalize Dependent: requirements in
>n/v understanding on >Regulate IVF as >For hydration and accordance with her
the health teachings ordered replacement of activity level and
Nsg Dx: about the fluids & electrolytes metabolic needs.
Imbalanced importance of good
Nutrition: Less than nutrition. Partially Met:
Body Requirements If after 8 hours of
LTO: After 3 days of nursing
nursing Therapeutic: interventions, the
interventions, >Provide parenteral >For hydration and patient will have
patient will have an fluids as ordered replacement of difficulty in
increased fluids & electrolytes understanding the
nutritional intake Educative: health teachings
and absence of Instruct on the given.
nausea and following:
vomiting. >Increase fluid >For hydration Not Met:
intake If after 8 hours of
>Avoid eating spicy, >Avoid increase in nursing
fatty or high- intestinal osmotic interventions, the
carbohydrate foods; pressure and patient will have
caffeine; sugar-free increased difficulty in
foods with sorbitol. peristalsis. understanding the
>Proper food >Avoid food health teachings
preparation contamination. given and the
patient shows non-
compliance to
health teachings.
REFERENCES: Carpento-Moyet, L.J.(2010). Handbook of Nursing Diagnosis: 13th Edition.
4 Nursing Care Plans for AGE. (2017). Retrieved September 19, 2017 from https://nurseslabs.com/gastroenteritis-nursing-care-plans/4/