a.

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: patient Acute Short Term Independent Independent Short Term
started to have Gastroenteritis
Within 30-40 - Evaluate pattern - Defecation GOAL MET
multiple episodes with moderate
minutes of nursing of defecation. pattern will
of LBM and dehydration and After 30-40
care, the patient - Assess the promote
vomiting as Autism Spectrum minutes of nursing
will be able to: volume and immediate
verbalized by the Disorder intervention, the
frequency of treatment.
mother. - Make a well- patient was able to:
vomiting. - Vomiting is
informed
- Assess the associated with - Make a well-
choice about
consistency and fluid loss. informed
Objective: the kind of
number of - Gastroenteritis choice about
pain relief the
 weak bowel is associated the kind of
patient would
 sunken movements. with an pain relief the
like to employ.
eyeballs - Provided increased patient would
- Actively
 dry lips comfort frequency of like to employ.
engage in
 buccal measures such very loose or - Actively
learning as she
mucosa as back rubs and watery bowel engage in
becomes
comforting movements. learning as she
familiar with
positions. The becomes
various
V/S as follows - Made the inflammation in familiar with
anxiety-
environment the large various
reduction
 Temp- quiet. intestine limits anxiety-
approaches.
36.7 *C - Observed the colon’s reduction
 CR- 110 - Express her nonverbal ability to absorb approaches.
bpm emotions, symptoms of water, leading
inadequate pain to fluid volume - Express her
worries, and
management. deficit. emotions,
 RR- 21 fears about
worries, and
cpm going into
fears about
 labor. going into
 BP- labor.
- To help the
100/80
patient be
mmHg Long Term
comfortable.
Long Term
Within 3 hours of
 SpO2-
nursing GOAL MET
96% Dependent*
intervention, the - To provide the
After 3 hours of
patient will be able patient with a
nursing
to: comfortable
- Administered IV intervention, the
environment so
- Lessened medication as patient was able
she can rest
discomfort prescribed by to:
without any
after receiving the physician. deterrents. - Lessened
painkillers.
Collaborative discomfort
-
after receiving
- None painkillers.
Dependent:
- To reduce pain.

Collaborative
- None