Patient Name: Sr.

Efleda Catipon
Dx: Acute Gastroenteritis
SN: Idea, Pamela A.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Data: “Deficient Fluid Short Term Independent 1. Gain a good patient- After 8 hours shift,
“Malambot po yung Volume related to Planning: 1. Establish trust and nurse relationship. goal is partially met.
dumi niya at color fluid loss secondary rapport. 2. Establish baseline Patient are able to
yellow” as verbalized to Diarrhea as After 8 hours shift, 2. Assess the vital data observations. bring back his normal
by the patient’s evidenced by dry and the patient will be signs and compare 3. This will provide a pattern of fecal
guardian. flaky skin, poor skin able to achieve it with the normal data that could be elimination and
turgor, yellowish and normal pattern of pattern. used to evaluate the improved her
watery stool” fecal elimination and 3. Assess for the proper intervention hydration status.
exhibit signs of signs of that the client needs.
improvement in dehydration 4. To reduce dryness of
Objective Data: hydration status. including skin the mucosa and
 Generalized turgor, oral mucosa, integumentary; and to
weakness etc. prevent dehydration.
 Dry and flaky 4. Encourage the 5. To determine if IV fluid
skin client to increase and electrolyte For the long term goal
 Pale nail Long Term the fluid intake. replacement are after days of therapy
beds Planning: 5. Monitor I & O and needed. patient are able to
 Delayed After days of nursing IV fluids. 6. To promote bring back her
capillary refill intervention, the 6. Provide health awareness on related strength, gained back
 Poor skin patient successfully teachings on factors. her normal stool
turgor able to prevent avoidance of 7. To give patient output, color and
 Yellow and dehydration due to dehydration. comfort. characteristic. The
watery stool Diarrhea and 7. Provide patient patient is also able to
Impaired Bowel opportunity to rest maintain her hydration
VS Taken as Movements. and calm and safe as evidenced by good
follows 4pm: environment. skin turgor and moist
T: 36.1°C mucosa and skin.
PR: 83 Dependent
RR: 21 8. Based on the result
BP: 100/80 or fecalysis.
8pm: 9. Administer
T: 36.4°C medication
PR: 90 prescribed by the
RR: 22 physician.
BP: 100/80
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: “Gastrointestinal Short Term Planning: Independent 1. Gain a good After 8 hours shift, goal
“2 weeks na po siyang infection as related to 1. Establish trust patient-nurse is partially met. Patient
nag LBM bago po Diarrhea as evidenced After 8 hours shift, the and rapport. relationship. are able to reduce
maadmit dito by frequent watery patient will be able to 2. Assess the vital 2. Establish fecal elimination, but is
hanggang ngayon po stools” report reduction in signs and baseline data still yellowish in color
madalas pa din po ang frequency of stools. compare it with observations. and watery in
pagdumi niya” as the normal 3. To help characteristics.
verbalized by the pattern. differentiate
patient’s guardian. 3. Observe and individual
record stool disease and
frequency, assesses
characteristics, severity of
Long Term Planning: amount and episode.
After days of nursing precipitating 4. To give patient
Objective Data: intervention, the factors. comfort. After days of therapy,
 Generalized patient successfully 4. Provide patient goal is fully met.
weakness able to prevent and opportunity to Patient are able to
 Increased achieve normal pattern rest and calm bring back her normal
peristalsis of fecal elimination. and safe fecal elimination, stool
 Frequent environment. normal color and
watery stools characteristics.
Dependent
5. Give 5. To gain
VS Taken as follows medications as nursing-patient
4pm: ordered by intervention
T: 36.1°C physician. with rapport to
PR: 83 6. Cooperate with care givers and
RR: 21 the family to to give hope for
BP: 100/80 serve foods better status of
8pm: that can help to health.
T: 36.4°C improve bowel 6. To facilitate
PR: 90 movements of balanced food.
RR: 22 patient.
BP: 100/80
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
 Subjective Data: “Risk for Inflammatory Short Term Planning: Independent 1. Gain a good After 8 hours shift, goal
“Minsan nasakit tyan Bowel Disease 1. Establish trust patient-nurse is partially met. Patient
ko tapos minsan secondary to Diarrhea After 8 hours shift, the and rapport. relationship. are able to feel relief
pabalik balik lagnat ko as evidenced by patient will be able to 2. Assess the vital 2. Establish from pain and achieve
o ‘di kaya’y sinat” abdominal cramps” relieve abdominal pain signs and baseline data normal body
and will also be able to compare it with observations. temperature, but it still
return to her normal the normal 3. To give patient may occur.
body temperature. pattern. comfort.
3. Provide patient 4. To promote
opportunity to relaxation and
Objective Data: rest and calm pain reduction.
 Generalized and safe
weakness environment.
 Guarding 4. Teach patient in
behavior at Long Term Planning: diversionary After days of therapy,
abdomen After days of nursing activities in goal is fully met.
 Warm to touch intervention, the easing pain. Patient are able to
patient successfully prevent episodes of
able to prevent abdominal pain and
abdominal pain. The Dependent intermittent fever.
patient will also be
able to prevent Administer and
frequent hyperthermia. prescribed
VS Taken as follows Paracetamol +
4pm: tramadol 1 cap TID
T: 36.4°C PRN x Pain,
PR: 87 Paracetamol 500mg
RR: 21 PRN x Fever
BP: 110/70
Patient
8pm: Name: Sr. Efleda Catipon
Dx:
T: Acute
37.9°C Gastroenteritis
PR: 101
SN: Idea, Pamela A.
RR: 21
BP: 110/70
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: “Gastrointestinal Short Term Independent 1. Gain a good patient- After 8 hours shift,
“2 weeks na po siyang infection as related to Planning: 1. Establish trust and nurse relationship. goal is partially met.
nag LBM bago po Diarrhea as rapport. 2. Establish baseline Patient are able to
maadmit dito evidenced by After 8 hours shift, 2. Assess the vital data observations. reduce fecal
hanggang ngayon po frequent watery the patient will be signs and compare 3. To help differentiate elimination, but is still
madalas pa din po stools and abdominal able to report it with the normal individual disease and yellowish in color and
ang pagdumi niya” as cramps” reduction in pattern. assesses severity of watery in
verbalized by the frequency of stools. 3. Observe and record episode. characteristics. The
patient’s guardian. The patient will be stool frequency, 4. To promote relaxation patient are also able
able to relieve characteristics, and pain reduction. to feel relief from pain
“Minsan nasakit tyan abdominal pain and amount and 5. To give patient and achieve normal
ko tapos minsan will also be able to precipitating comfort. body temperature, but
pabalik balik lagnat ko return to her normal factors. it still may occur.
o ‘di kaya’y sinat” body temperature. 4. Teach patient in
diversionary
activities in easing
pain.
Objective Data: Long Term 5. Provide patient For the long term goal
 Generalized Planning: opportunity to rest after days of therapy
weakness After days of nursing and calm and safe patient are able to
 Dry and flaky intervention, the environment. bring back her normal
skin patient successfully fecal elimination, stool
 Pale nail beds able to prevent and Dependent normal color and
 Delayed achieve normal 6. Cooperate with the 6. To gain nursing-patient characteristics. The
capillary refill pattern of fecal family to serve intervention with rapport to patient are also able
 Poor skin elimination. The foods that can help care givers and to give hope to prevent episodes of
turgor patient will also be to improve bowel for better status of health. abdominal pain and
 Yellow and able to prevent movements of 7. To facilitate balanced intermittent fever.
watery stool abdominal pain and patient. food.
frequent 7. Administer
VS Taken as follows hyperthermia. medication
4pm: prescribed by the
T: 36.1°C physician.
PR: 83
RR: 21 Administer and prescribed
BP: 100/80 Paracetamol + tramadol 1
8pm: cap TID PRN x Pain,
T: 36.4°C Paracetamol 500mg PRN x
PR: 90 Fever
RR: 22
BP: 100/80