NURSING CARE PLANS CUES Subjective: Matubig yung dumi niya, madalas din siyang magsuka as verbalized by patients

guardian. Objective: Frequent watery stools with foul smell (2-3x per shift). (+) vomiting (2x day) Sunken anterior fontanel Weaklooking Irritable Dry mucous membrane Fluid Volume Deficit related to frequent passage of watery stool and vomiting. NURSING DIAGNOSIS NURSING GOAL Bacteria that After 8 hours of are present in nursing the body adhere interventions, to mucosa to the patient will avoid being maintain swept away adequate fluid then binds to volume as the receptors on evidenced by the intestinal surfaces. a. Reducti Mucosal on in adherence frequency of causes changes watery to the gut stools. epithelium that b. (-) may reduce its vomiting absorptive c.Moist capacity or mucous cause fluid membrane secretion. d. Good skin turgor RATIONALE INTERVENTION Independent: Observe and record stool frequency, characteristics, amount and precipitating factors. Promote bed rest. Helps differentiate individual disease and assess severity of episode. RATIONALE EVALUATION The goal was met as evidenced by: a. Reduction in frequency of stools (1x per shift) b. No vomiting c. Moist mucous membrane. d. Good skin turgor

Rest decreases intestinal motility and reduces metabolic rate. Avoiding intestinal irritants promotes intestinal rest. Fruits that are stool former.

Identify foods and fluids that precipitate diarrhea.

Encourage to eat

foods like latundan banana and apple.

Teach significant others how to properly feed the patient and give

To prevent recurrence of the disease.

some precautionary measures. Weigh daily. Indicator of overall fluid and nutritional status. To prevent further dehydration. To help prevent proliferation of bacteria.

Collaborative: Replace Fluid losses volume per volume. Administer medications as prescribed by the physician.

NURSING DIAGNOSIS Subjective: Hyperthermia Mainit na naman related to siya, may lagnat presence of ba? as verbalized infection. by the patients guardian. Objective: Flushed skin, warm to touch. Restless Irritable Teary eyed Chills noted Tachycardia V/S taken as follows: T: 39.3 C P: 156 bpm R: 37 cpm BP: 100/60 mmHg

CUES

RATIONALE The systemic inflammatory response syndrome is characterized by synthesis and release of pyrogenic cytokines from a variety of cells. These cytokines, in turn, trigger specialized endothelial cells of the hypothalamic vascular organs, resulting in a resetting of the hypothalamic thermostat from normothermic to febrile levels.

NURSING GOAL After 4 hrs. Of nursing interventions, the patient will maintain core temperature within normal range, be free from chills.

INTERVENTION Independent:
Monitor body

RATIONALE

EVALUATION

temperature, heart rate and rhythm.

After 4 hrs. Of nursing interventions, the To have a patient was able baseline data maintain core regarding the onset of fever and temperature within normal range and note other direct effect of fever in free from chills. cardiac tissues.

Promote surface To decrease cooling by means of temperature by tepid sponge bath. means through evaporation and conduction. Monitor environmental temperature/limit or add linen as indicated. Room temperature/num ber of blankets should be altered to maintain near body temperature. To reduce metabolic demands and oxygen consumption

Maintain bed rest.

Collaborative: Administer antipyretics orally or rectally as prescribed by the physician. Administer replacement fluids and electrolytes To facilitate fast recovery.

To support circulating volume and tissue perfusion.

CUES Subjective: Bakit may mga pantal siya sa katawan, as patients guardian verbalized. Objective:
Presence of

NURSING DIAGNOSIS Impaired Skin Integrity due to presence of rashes.

RATIONALE The rash is caused by small blood vessels in the skin leaking blood into the tissues, where the blood forms a small red patch with irregular shape but quite sharp edges. As the color is from red blood cells that are unable to move, pressing on the skin does not change their color.

NURSING GOAL After 1-2 days of nursing intervention, the patient will have improved skin integrity as evidenced by reduction of rashes.

NURSING INTERVENTION Independent Assess patient skin thoroughly.

RATIONALE

EVALUATION The goal was met as evidenced by absence of rashes.

To determine

if rashes developed in other parts of the body. To maintain skin integrity at optimal level. Clotting factors may show abnormal result that may increase the patient risk. Rashes may cause itchiness.

Maintain strict hygiene. Monitor laboratory results pertinent to causative factors. Promote patients comfort. Collaborative Give medications as prescribed.

maculopapular rash on truck and lower extremities. (+) LATS

To relieve any discomfort.