CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
Igtanloc, Jocely, I.
BSN 2C3
ASSESSMENT
Subjective Data:
The baby was reported to
have had 10 watery stools
over the previous 24 hours,
during which she became
quite unsettled, restless,
irritable, crying a lot, whilst
drinking half her usual
amount of liquids/milk.
Vomited for 4 times for the
last 24 hours was also
reported.
Mother claimed that
“Alyzzia is still on bottle
feeding with powder milk
formula”
Mother claimed that Alyzzia
cannot “fall to sleep” unless
finishing 2 bottles with 10
ounces of milk formula.
Name and Group Number
MANILA*MAKATI*MALOLOS
NURSING CARE PLAN
Acute Gastroenteritis
NURSING DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS SCIENTIFIC EVALUATION
EXPLANATION (IMPLEMENTATION) RATIONALE
Risk for infection due Acute Gastroenteritis Long term Outcomes: Independent Nursing Action: Independent Nursing Action: Discharge Outcome:
to insufficient is also known as Discharge Outcomes Upon Discharge, the
knowledge to prevent infectious diarrhea, it 1. Obtain baseline vital 1. Fluid and electrolyte client:
contamination is the inflammation of signs and monitor every imbalances can alter 1. Client has
(Inappropriate hand the gastrointestinal 1. Client will be 2-4 hours. vital body functions. reduced
hygiene, and food tract that involves reduced . frequency of
handling) stomach and small frequency of 2. Observe and record stools.
2. Aids in diagnosis and
intestine. Sign and stools. stool frequency,
in monitoring the child
symptoms include characteristics, amount
status
some combination of 2. Client’s stool and precipitating 2. The patient’s
diarrhea, abdominal will able to factors. stool has
pain, fever, lack of return to more returned to
3. To avoid intestinal
energy, and normal stool 3. Identify foods and more normal
irritants that can
dehydration. Elevated consistency. fluids that precipitate stool
promote intestinal
WBC and platelets are diarrhea like milk, consistency.
irritation.
an indicator of vegetables and fruits.
infection and also 3. Client will no 3. The patient has
4. It helps determine the
there is a presence of longer be 4. Monitor Intake and been settled,
character of the stool
E. coli. unsettled, Output. Note character, not restless, or
and indicate fluid
restless, or and number of stools, irritable.
balance for the client.
irritable. estimate insensible
fluid losses.
Submitted to:
 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

Alyzzia is also into pacifier
and always with her is a
small pillow as her “security
blanket”.
As mentioned by the mother
Alyzzia received the
following vaccine: “BCG,
Hepatitis B, pentavalent,
oral polio, MMR”
Objective Data:
➢ Medical history
revealed delivery at
term via normal
spontaneous
delivery, cephalic
presentation, with a
birth weight of
3910 g.
Reference: Elliott, E. J. Short term Outcome: 5. Wash hands well 5. Helps prevents Short term Outcome:
(2007). Acute After 1 hour of nursing before and after transmission of After 1 hour of nursing
gastroenteritis in
intervention the contact with the child. microorganism. intervention the
children. Bmj, 334(7583),
35-40. clients: clients:
Collaborative Nursing Action: Collaborative Nursing Action:
1. Fever will be 1. Administer prescribed 1. Provides necessary 1. Fever is
manageable or oral dehydration and fluids and nutrients to manageable or
within normal intravenous solutions the child. within normal
range range
2. Skin turgor, dry 2. Notify the physician if 2. To ensure early 2. Skin turgor, dry
lips and dry diarrhea persists, stool intervention. lips and dry
buccal mucosa characteristics change, buccal mucosa
will be or other symptoms of has improved.
improved. dehydration/
electrolyte imbalance
occur

➢ Apgar score was 7-8

at one and five
minutes,
respectively.

Name and Group Number Submitted to:

 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

➢ Upon physical
examination
revealed an alert but
irritable and ill-
appearing infant.
Vital Signs:
T: 39.9C
PR: 145 and 160 beats/min
RR: 40 and 50 breaths/min
O2 saturation: 100%

Weight upon admission is

10.8 kg

➢ Skin was pale grey

➢ Tenting skin turgor
➢ Dry lips
➢ Dry buccal mucosa
Sunken eyes and
reduced tears
➢ Capillary refill time of
3 seconds.

➢ Urine output was

also decreased.

➢ Heart and lung

examination were

Name and Group Number Submitted to:

 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

normal except for

tachycardia

➢ The abdomen was

swollen and slightly
painful on palpation,
no
hepatosplenomegaly.

➢ Abdominal and
thorax radiographs
were normal.

➢ There were no signs

of meningeal
irritation.

➢ Routine stool
specimen tested
positive for E. coli
whilst results for
blood and urine
culture were
negative.

Other Laboratory as follows:

Name and Group Number Submitted to:

 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

WBC/PMN (*109 /L) Result:

18/7.6
Normal range: 6–17.5/1.0–
8.5

Hb (g/dL)/ Ht (%)
Result: 12.6/ 42.2
Normal range: 11.1–14.1/
31–41

Platelets (*109 /L)

Result: 1085
Normal range: 300–750

CRP (mg/dL)
Result: <0.05
Normal range: <1

pH
Result: 7.21
Normal range: 7.38-7.46

Bicarbonate/base excess
(mEq/L)
Result: 8/-19.3
Normal range: 24-30/(-)3-
(+)3

Name and Group Number Submitted to:

 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

BUN (mg/dL)
Result: 61
Normal range: 10-50

Na (mEq/L)
Result: 146
Normal range: 129-143

Name and Group Number Submitted to:

 CENTRO ESCOLAR UNIVERSITY
SCHOOL OF NURSING
MANILA*MAKATI*MALOLOS

NURSING CARE PLAN

References:
Freedman, S. B., Adler, M., Seshadri, R., & Powell, E. C. (2006). Oral ondansetron for gastroenteritis in a pediatric emergency department. New England Journal of Medicine, 354(16), 1698-1705

Elliott, E. J. (2007). Acute gastroenteritis in children. Bmj, 334(7583), 35-40

GASTROENTERITIS, S. O. A. (1996). Practice parameter: the management of acute gastroenteritis in young children. Pediatrics, 97(3), 424-435

Hartman, S., Brown, E., Loomis, E., & Russell, H. A. (2019). Gastroenteritis in children. American family physician, 99(3), 159-165.

Mushtaq, A., Khan, S., Zeb, F., Ain, Q., Syed, A., & Khattak, F. (2016). Risk factors associated with gastroenteritis in children 2-5 years of age attending Rehman Medical Institute
Peshawar. American Journal of Food Science and Health, 2(5), 94-101.

Burkhart, D. M. (1999). Management of acute gastroenteritis in children. American Family Physician, 60(9), 2555.

Name and Group Number Submitted to: