Patient Name: Boral, Jilian Age :2y/o Diagnosis: AGE with Moderate Dehydration

Cues Diagnosis Rationale Planning Intervention Rationale Expected Outcome

Subjective:tubig pa ang udo nia,weak and pale in appearance ,slow skin turgor Objective: T-36.5 CR- 110 RR- 30

Deficient Fluid volume r/t Frequent passage of loose watery stool evidenced by dehydration.

AGE is an inflammation of the stomach and intestinal tract that primarily affects the small bowels.

At the end of 8 hours shift the patient will maintain normal fluid volume, normal skin turgor and intake is equal to output.

Establish rapport Monitor and record VS Monitor input and output Maintain adequate hydration, increase fluid intake Provide frequent oral care

To gain patients trust To obtain base line data To ensure accurate fluid status To prevent dehydration

After 8 hours interventions the patient shall have maintained fluid intake is equal to output and normal skin turgor.

To prevent from dryness

Subjective: makulog daa tulak niya, facial grimace noted, irritable and fussy, crying ,P/S=6/10 Objective : T-36.5 CR- 110 RR- 30

Acute pain r/t S.O verbalization as manifested by facial grimace, crying , P/S of 6/10.

After 8 hours nursing interventions the patient pain will be reduced or controlled.

Observe and document location ,severity and characteristics Promote bed rest and in low fowlers position

Encouraged Diversional activities like offering the favorite toys Provide comfort measures such as touch and change in desirable position Note when pain occurs

To rule out worsening of At the end of the shift the underlying patient pain was reduced condition/ and controlled. development of complications. Bed rest in low fowlers position reduces intra-abdominal pressure To divert patient attention

To promote nonpharmacolo gical management

To medicate prophylactically

Subjective: complaint of bodyweakness,pale in appearance Objective: T-36.5 CR- 110 RR- 30

Activity intolerance r/t bodyweakness as manifested of pale in appearance.

At the end of 8 hours shift the patient will report measurable increase in activity intolerance.

Note presence of fatigue

Note report of weakness,fatigue, pain, difficulty accomplishing tasks Assisting the client in performing ADLS Perform moderate exercise

Fatigue affects both the patients actual and perceived ability to participate in activities. Symptoms may be result of/or contribute to intolerance of the activity. To prevent/protect client from injury To strengthen the muscles

After the shift paient would increased in strength /activity intolerance.