NURSING CARE PLAN

Name: _Budoy_______________________________ Age: _4yrs and 9 mos.______________________ Date: August 20, 2021
Address: ____Brgy. Santiago, Nabua Camarines Sur___________ Clinical Diagnosis: ___Acute Gastroenteritis (AGE) with Dehydration__
Nursing
Cues Rationale Planning Nursing Intervention Rationale Evaluation
Diagnosis
Subjective: Deficient fluid Acute Short term: Independent: Short term:
“My son is weak and volume related to Gastroenteritis is After 36 hrs of nursing  Urge the patient to  Oral fluid replacement After 60 hrs of
also warm when I active fluid inflammation of the intervention patient will drink prescribed is indicated for mild nursing
touch him” as volume loss as lining of the stomach maintain fluid volume at amount of fluid. fluid deficit and is a intervention,
verbalized by Pt.’s evidenced by and small and large a functional level with cost-effective method patient maintained
mother. vomiting, intestines. The most good skin turgor and for replacement fluid volume at
-Abdominal pain diarrhea, poor common cause of moist lips and oral treatment. functional level
skin turgor, dry this disease is mucous membrane. evidenced by:
lips and dry oral infection obtained Vomiting and diarrhea  Aid the patient to  Dehydrated patients -good skin turgor
Objective: mucus from consuming will not be noted. eat, and encourage may be weak and - moist lips and
- Persistent vomiting membrane. food or water. The the family or SO to unable to meet oral mucus
- Passage of watery most common assist with feedings, prescribed intake membranes
stool symptom of the said Long term: as necessary. independently. The goal was met
- Poor skin turgor disease is vomiting After 1 week of nursing since vomiting and
- Hyperactive bowel accompanied with shift, patient’s mother will  Provide fluid and  For easy diarrhea was
sounds w/ audible diarrhea. As this two be educated on the straw at bedside consumption or absent.
borborygmic sounds symptoms occur, procedure appropriate to within easy reach. intake of fluid
-Dry lips and oral active fluid volume the prevention of risks Provide fresh water Long term:
mucus membranes loss which is where that might contribute to and a straw. Patient’s mother
V/S: the fluid output another occurrence of understood clearly
T- 38.4 degrees C exceeds the fluid Acute Gastroenteritis.  Provide comfortable  Drop situations the procedure on
PR – 97 bpm intake thus causing She will also be environment by where patient can the prevention of
RR- 25 cpm poor skin turgor and knowledgeable on covering patient with experience another
dry lips and dry oral monitoring of deficit as light sheets. overheating to occurrence of
mucus membrane. indicated. prevent further fluid Acute
loss. Gastroenteritis
and was able to
 Enumerate  Patient needs to monitor deficits of
interventions to understand the the patient.
 patient’s SO to value of drinking
prevent or minimize extra fluid during
future episodes of bouts of diarrhea,
dehydration. fever, and other
conditions causing
fluid deficits.
 Teach family  An accurate
members how to measure of fluid
monitor output in the intake and output is
home. Instruct them an important
to monitor both indicator of patient’s
intake and output. fluid status.

 Begin to advance  Addition of fluid-rich

the diet in volume foods can enhance
and composition continued increase
once ongoing fluid of fluid input.
losses have
stopped.

Dependent:
 Administer  Fluids are necessary
parenteral fluids as to maintain
prescribed. hydration status.

Nursing
Cues Rationale Planning Nursing Intervention Rationale Evaluation
Diagnosis
Diarrhea related As bacteria or viral Short term: Independent: Short term:
to viral/bacterial infection causes After 48 hrs of nursing  Monitor abdominal  To determine Patient
infection as Acute intervention, patient will pain, hyperactive changes of bowel demonstrated
evidenced by Gastroenteritis, reestablish normal bowel sounds, sounds, severity of normal pattern of
watery stool, Diarrhea is usually a pattern of bowel frequency, urgency abdominal pain, bowel
abdominal pain result of this functioning as evidenced and loose stools. frequency, urgency functioning. No
and hyperactive problem. It is one of by absence of abdominal and consistency of abdominal pain
bowel sounds the nursing pain and watery stool. stool
was noted.
with audible diagnosis due to the Hyperactive bowel
borborygmic fact that there is sounds will not be noted.
Hyperactive
 Promote use of  To decrease stress
sound. watery stool, Patient’s SO will relaxation technique and anxiety
bowel sound was
abdominal pain and verbalize understanding absent. Patient’s
hyperactive bowel of causative factors and  Advise the client’s  These food items can mother clearly
sounds that rationale for treatment mother to restrict the irritate the lining of comprehended
translates to regimen. intake of milk and the stomach, hence the factors that
stomach and dairy products. may worsen diarrhea. caused the
intestines that are Long term: illness.
irritated and After 1 week of nursing  Encourage the  When a client
inflamed. shift, patient’s SO will be client’s mother to eat experience diarrhea, Long term:
able to demonstrate foods rich in the stomach contents Patient’s mother
appropriate behaviour to potassium. which is high in
assist with resolution of
prepared foods
potassium get flushed that were
causative factors with out of the
proper food preparation appropriate to
gastrointestinal tract
and avoidance of into the stool and out the client’s
irritating foods. of the body, resulting condition.
in hypokalemia. Avoided foods
that would cause
 Educate the client’s  The anal area should irritation to the
SO about perianal be gently clean bowel system.
care after each properly after a bowel
bowel movement. movement to prevent
skin irritation and
transmission of
microorganism.

Dependent:
 Administer  To decrease
antidiarrheal gastrointestinal
 medications as motility and minimize
prescribed. fluid losses.

 Administer IV fluids,  IV fluids is needed for

electrolytes, enteral short term to restore
and parenteral fluids hydration status
as prescribed

Interdependent:
 Prepare dietary meal  Dietary meal plans
plan are recommended in
order for SO to be
knowledge on what
food is appropriate for
consumption

Nursing
Cues Rationale Planning Nursing Intervention Rationale Evaluation
Diagnosis
Hyperthermia Patient is diagnosed Short Term: Independent: Short term:
related to viral with hyperthermia After 36 hrs of nursing  Monitor patient’s V/S  HR and BP increase After 48 hrs of
infection process due the fact that the shift, patient will be able as hyperthermia nursing
as evidenced by body temperature maintain normal core progresses. intervention,
body temperature needs to rise in temperature within Tympanic or rectal patient displayed
of 38.4 degrees C order to fight of the normal range. temperature gives a normal core
infection in V/S: more accurate temperature.
eradicating the T – 37.1 degrees C indication of core T – 36.8 C
bacteria or virus temperature.
present within the Long Term: Long Term:
body. The infection After 3 days of nursing  Adjust and monitor  Room temperature Patient’s mother
triggers a chain shift, patient’s mother will environmental may be accustomed demonstrated how
reaction throughout be knowledgeable on factors such as room to near normal body to successfully
the body and most how to measure temperature and bed temperature and measure body
often stars in the temperature, at what linens as indicated. blankets and linens temperature, was
gastrointestinal body temperature to give may be adjusted as oriented on the
tract. antipyretic medication, indicated to regulate proper
and what symptoms to temperature of the administration of
report to the physician patient. antipyretic
along with, will be able to medications and
perform normothermia.  Eliminate excess  Exposing skin to oriented on
clothing and covers. room air decreases performing
warmth and normothermia.
increases evaporative
cooling.

 Encourage fluid  If the patient is

intake by mouth. dehydrated or
diaphoretic, fluid loss
contributes to fever.

 Discuss to patient’s  To prevent

mother the dehydration
importance of
adequate fluid intake
at all times and ways
to improve hydration
status

Dependent:
 Give antipyretic  Antipyretic
medications as medications lower
prescribed. body temperature by
blocking the
synthesis of
prostaglandins that
act in
 Administer antibiotic the hypothalamus.
medication as  To treat underlying
 prescribed cause for infection

Interdependent:
 Provide high caloric
diet as indicated  Appropriate diet is
necessary to meet
the metabolic
demand of the
patient.
Prepared by: Submitted to:

______Kyle Josef V. Vargas_________________ Jocyl Darrel B. Abinal, R.M, R.N, MAN

Student Clinical Instructor