NURSING CARE PLAN

Patient profile: L.V Age: 2 months old Name of Student: Trisha Ericka Surigao BSN 4-A1
Complaints: Vomiting Inclusive Date & Areas: May 2, 2024
Admitting Dx: Acute Gastroenteritis Clinical Instructor: Jannyline A. Guminang, RN

DATE CUES N NURSING OBJECTIVE INTERVENTIONS EVALUATION

E DIAGNOSIS OF CARE
E
D
S

May Subjective: P Imbalanced SHORT TERM INDEPENDENT SHORT TERM

2, H Nutrition: Less
2024 “Ginasuka Y Than Body After 8 hours of ● Monitor weight daily After 8 hours of
niya iyahang S Requirements nursing interventions, and compare to nursing
gina-dede, I Increased the client will be able growth charts. interventions, goal
Maam. Mao O nutritional losses to: Rationale: Tracks growth met as evidenced
nag-decide L due to vomiting and detects potential by:
mi na ipa- O secondary to ● Tolerate inadequate intake.
admit na G acute feedings with ● Assess feeding ● Client tolerated
siya,” as I gastroenteritis as minimal vomiting history, including type feedings as
stated by the C evidenced by or diarrhea. of feeding evidenced by
parents. A frequent vomiting. ● Demonstrate (breastfeeding, no episodes of
L adequate intake formula), frequency, vomiting and
Objectives: RATIONALE: of breast milk amount, and diarrhea
N tolerance. ● Demonstrated
● Increasing E The inflammation LONG TERM Rationale: Identifies adequate
abdominal E of the potential issues affecting intake of breast
girth - D gastrointestinal After 2 days of intake. milk as
from 43 S tract caused by nursing interventions, ● Monitor intake and evidenced by 2
 cm of last acute the client will be able output (I&O), including wet diapers and
shift to 44 gastroenteritis to: frequency and amount weight stability.
cm disrupts the of breast milk/formula
● Irritability normal digestive ● Maintain weight intake, urine output LONG TERM
process. Frequent within expected (wet diapers), and
vomiting prevents range for age and stool output. After 2 days of
the infant from growth or Rationale: Assesses fluid nursing
absorbing demonstrate balance and potential interventions, goal
nutrients minimal weight dehydration. met as evidenced
effectively, leading loss ● Observe for signs and by:
to imbalanced symptoms of
nutrition and dehydration ● Maintained
inadequate intake. Rationale: Helps identify weight within
potential complications expected range
REFERENCE: from inadequate intake. as evidenced
● Assess for signs of by weight
NANDA, eleventh abdominal discomfort stability within
edition Rationale: Evaluates last 2 days of
factors affecting feeding admission
tolerance.
● Offer frequent, small
feedings
Rationale: This reduces
the risk of overwhelming
the stomach and
minimizes vomiting.
● Position the infant
upright during feeding
and for 30 minutes
afterward
Rationale: This helps
keep stomach contents
down and prevents
aspiration.
● Monitor for feeding
cues
Rationale: Look for signs
of hunger like rooting,
sucking motions, and
hand-to-mouth
movements.
● Provide oral care
frequently
Rationale: Prevent
dryness and discomfort.
● Document intake and
output accurately
Rationale: Accurately
documenting intake and
output allows for
assessment of fluid
balance and identification
of potential dehydration
or excessive losses.

DEPENDENT:

● Administer
medications as
prescribed by the
physician
Rationale: This may
include antiemetics
(medications to reduce
vomiting) or
antidiarrheals
(medications to reduce
diarrhea) depending on
the specific symptoms.
● Provide oral
rehydration solution
(ORS) between
feedings as
prescribed by the
physician
Rationale: Offer ORS as
prescribed by the
physician to replace fluids
and electrolytes lost
through vomiting and
diarrhea.

COLLABORATIVE:

● Collaborate with the

physician to monitor
weight and adjust
feeding plan as
needed
Rationale: The physician
may recommend
supplementing breast
milk or formula with
calorie and nutrient-rich
fortifiers if oral intake
remains insufficient.
● Monitor laboratory
tests as ordered
(electrolytes)
Rationale: Electrolyte
imbalances can occur
due to vomiting and
diarrhea.