Nursing of the Childbearing Family

Nursing Care Plan (ADPIE)

Assessment Diagnosis Planning Implementation Rationale Evaluation

Objective Data Fluid volume deficit Client Goal Independent Interventions
Bp 96/68, RR20, r/t diarrhea, vomiting Pt. will be free of 1.Observe stools for
Aids in determining
HR120 diarrhea and vomiting amount, color, Child’s bowel function
and in monitoring the
T 37.2C (98.9F), an consistency, odor and will return to normal
child’s status
BUN 20 frequency
Creatinine 0.9 Child will have normal
Contributes to fluid
2. Assess for vomiting fluid and electrolyte
volume deficit
balance

3.

4.

5.

Subjective Data Theory Goal Evaluation Interdependent Interventions

(cite references) Healthcare Profession Rationale Evaluation
Parent reports Gastroenteritis is the Client will tolerate
vomiting and diarrhea inflammation of the feeding and 1.
x 2-3 days stomach and the elimination patterns
intestines, typically will return to normal 2.
resulting from within an 8hr shift
bacterial toxins or 3.
viral infection and
causing nausea and
diarrhea. Children
with gastroenteritis
may waken freq. with
bouts of vomiting. IF
the child is
hospitalized it is
important to assess
onset, frequency,
color, amount and
consistency of stools.
If the child is vomiting
it is important to
monitor the amount
and type of vomitus.
Observe the child for
signs and symptoms
of dehydration, which
reflect underlying
fluid and electrolyte
imbalances Evaluate
urinary output and
specific gravity. An
accurate weight must
be obtained on
admission and daily
thereafter. Monitor
VS every 4 hrs.
promote rest and
comfort. Provide skin
care after each bout
of diarrhea. Liquids
are offered , small
amount of normal
diet for age are
provided. Discharge
teaching teaches the
parents the s/s of
dehydration and what
actions to take if the
diarrhea reoccurs.
Cited: Ball & Bindler,
6th edition, Chapter 25
Alteration in GI
Function