Assessment Nursing Nursing Intervention Rationale Evaluation

Diagnosis Goals

Secondary data: Short Term: Independent: Independent: Short term:

Risk for fluid 1) Observation of vital 1) To obtain baseline data.
“Mahigit tatlong beses volume deficit After 16 hours, the patient signs 2) To manage possible After 16 hours, the patient re-
dumudumi ng lusaw sa secondary to will re-establish the normal 2) Observation of signs complications safely and established the normal pattern of
isang araw at diarrhea and pattern of bowel of dehydration effectively. bowel functioning as evidenced by
nagsusuka si baby.” vomiting as functioning as evidenced 3) Encourage family to 3) To prevent dehydration; passage of semi solid stools.
As verbalized by the evidenced by by passage of semi solid provide 230-250 cc an appropriate drinking
mother decreased urine stools. of water and what water should be provided After 16 hours, the patient maintained
output, poor skin clear liquids to that is suitable for the fluid volume at functional level as
Method of turgor, and dry After 16 hours, the patient consume and avoid. patient’s age. evidenced by adequate hydration,
assessment: mucus membrane will maintain fluid volume at 4) Educate the 4) Early feeding reduces intake is equal as output, and normal
Interview functional level as patients’ parents illness and improves skin turgor.
evidenced by adequate about the nutritional outcome.
Objective data: hydration, intake is equal contributing factor Long Term:
as output, and normal skin that is causing their
T: 38.5 °C turgor. child’s diarrhea. After 3 days of nursing interventions,
Wt: 6.3 kg 5) Perform tepid 5) To reduce body the patient is free from diarrhea as
Long Term: sponge bath temperature evidenced by re-established and
Physical Exam maintained normal bowel movement,
After 3 days of nursing reduced in frequency of stools and
Dry mouth interventions, the patient stool returned to its normal
Poor skin turgor shall be free of diarrhea as consistency.
Dry mucus evidenced by re-
membrane established and maintained
Decreased normal bowel movement,
urine output (1 reduced in frequency of
soiled diaper in stools and stool returned to Dependent:
6 hours its normal consistency. 1) Administer
medications, as
ordered.  Dependent:
2) Administer an oral 1) To decrease GI motility
rehydration solution and minimize fluid
ORS for both losses.
rehydration and
2) 5) Increased fluid intake
replacement of
stool losses. replaces

Collaborative:

1) Collaboration with
physicians in Collaborative:
providing
therapeutic fluids, 1) To prevent medication
fluid, electrolyte lab error and deliver better
tests. patient outcomes
2) Collaboration with a
team of nutrition in
low-sodium fluids 2) To make an informed
decision about the
nutrition and health care
of the patient.
 Nursing Nursing Intervention Rationale Evaluation
Assessment Diagnosis Goals

Short Term: Independent: Independent: Short Term:

Secondary data: Imbalanced
nutrition less than After 8 hours, the child will 1. Provide a diet that 1) Helps meet the child’s After 8 hours of shift, the child has
“Walang po siyang body take 1,300 kcal for the day meets child’s daily maintenance and taken enough 1,300 calories for the
ganang kumain at requirements for the day and will retain caloric requirements growth needs. day from foods such as soft fruits,
nanghihina, kasi related to oral feedings without hesitation for 1 year old 1,300 vegetables, and foods rich in
kahapon pag- intake hesitation kcal/day such as protein as evidenced by retained
nalalamanan yung as evidenced by After 8 hours, the family soft fruits, feedings without hesitation
tiyan niya naiiyak, lack of interest in members will express vegetables, and
masakit siguro kaya food, recent understanding of important foods rich in protein After 8 hours, the family members
ngayon parang natakot weight loss, nutrition and will be able to 2. Provides small, 2) To reduce fatigue and expressed understanding of
ng kumain” as weakness and demonstrate understanding frequent feedings improve intake important nutrition and
verbalized by the fatigue. of other feeding techniques 3. Record and 3) To prevent demonstrated understanding of
mother describe food dehydration; an other feeding techniques
Long Term: intake. appropriate drinking
Method of water should be Long Term:
assessment: After 3 days of nursing provided that is
Interview interventions, the child will suitable for the After 3 days of nursing
exhibit no further weight patient’s age. interventions, the child exhibits no
Objective data: loss. 4. Promote adequate 4) To reduce child’s further weight loss.
rest by setting more fatigue and improve
Presence of After 3 days of nursing than 8 hours of the child’s desire to eat After 3 days of nursing intervention,
nausea and intervention, family sleep and peaceful family members expressed
vomiting members will express environment 5) To provide clues to willingness to continue feeding
willingness to continue 5. Monitor and record nutrient absorption. regimen at home.
Lack of interest feeding regimen at home. amount, color,
in food due to consistency, and
Poor muscle presence of occult
tone
blood in emesis and
Presence of stool
pain and
discomfort after
meal.
Dependent:
Lack of interest Dependent:
in food
1) To ensure adequate fluid
Recent weight 1) Provide therapeutic and electrolyte level
loss fluids and oral
medications as
Wt: 6.3 kg ordered

Collaborative:
Collaborative:
6. This team individualize the
1) Refer family child’s diet within
member to a prescribe restrictions.
dietician or
nutritional
support team for
dietary
management