NURSING CARE PLAN

CUES SUJECTIVE: When the client experienced diarrhea she defecates almost 3 times a day. According to her mother s description, the feces appearance is soft and slightly watery with light brown color. Naawa na nga ako sa anak ko kasi bigla na lang sumasakit ung tiyan niya at nagtatae na ng tubig. Sabi ng anak ko nanghihina na siya sa sobrang pagbabawas kaya dinala ko na siya sa health center. Pinainom ko lang siya ng gatorade kasi un lang naman ung alam kong iniinom kapag nagtatae ng sobra tsaka un din sabi ng mga kapit bahay namin . The client NURSING DIAGNOSIS GOALS/OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Goals: Fluid After 1 week of Volume intervention, the Deficit client will be able to related to restore the normal Diarrhea fluid volume and be and able to gain more Vomiting knowledge about as dehydration. manifested by Objectives: decreased urine 1. After 3 minutes of output, discussion, the sudden client will be able to weight give the definition loss, and of isotonic weakness. dehydration.

EFFECTIVENESS 1. The nurse was able to teach the client the definition of isotonic dehydration. > When treating dehydration, the type of water loss must be determined to ensure appropriate treatment Ref: http://www.novelguide.co m/a/discover/genh_0002_ 0002_0/genh_0002_0002 _0_00233.html 1. Was the client able to be able to give the definition of isotonic dehydration? Yes___No___Why?__

2. After 7 minutes of discussion, the client will be able to state 5 out of 7 causes of dehydration.

2. The nurse was able to teach the client the 7 causes of dehydration.

> When treating dehydration, the underlying cause must be addressed. Ref: http://www.novelguide.co m/a/discover/genh_0002_ 0002_0/genh_0002_0002 _0_00233.html

2. Was the client able to teach the client the 7 causes of dehydration? Yes___No___Why?__

3. After10 minutes of discussion, the client will be able to verbalize 7 out of 9 common signs and symptoms of dehydration.

3. The nurse was able to teach the client the 9 common signs and symptoms of dehydration.

>It is very helpful to evaluate symptoms and signs in diagnosing the causes of health problems and in monitoring the status of diagnosed diseases. Ref: http://www.medicinenet. com/symptoms_and_sign s/article.htm

3. Was the client able to teach the client the 9 common signs and symptoms of dehydration? Yes___No___Why?__

4. After 5 minutes of 4. The nurse > The risk of life- 4. Was the client able discussion, the was able to threatening complications to teach the client the client will be able to teach the client is greater for young 6 complications of

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urinates 2 times a day, about 300-400 ml per day. Hindi siya madalas umiihi sa tingin ko naman kasi ok lang yun . According to client s mother, the color of urine is dark colored. Nung nagkasakit siya, minsan walang ganang kumain The client is also experiencing vomiting approximately 4-5 times a day. The vomitus is watery with the foods the client ate in the previous meals. Client does not experience excessive perspiration. Client s daily activity is going to school and playing with her friends. give 5 out of 6 the 6 children and the elderly. dehydration? complications of complications of However, dehydration dehydration. dehydration. that is rapidly recognized Yes___No___Why?__ and treated has a good outcome Ref: http://www.novelguide.co m/a/discover/genh_0002_ 0002_0/genh_0002_0002 _0_00233.html

5. After 5 minutes of discussion, the client will be able to give 3 out of 4 ways on how to prevent dehydration.

5. The nurse was able to teach the client the 4 ways on how to prevent dehydration.

> Every individual & and healthcare provider should focus on primary prevention. It is usually the least expensive intervention and provides the greatest benefits. Ref: Foundations of Nursing by Lois White 2nd Edition p.261 Dehydration prevention is the best treatment for every age group Ref: http://www.symptomsofd ehydration.com/

5. Was the client able to teach the client the 4 ways on how to prevent dehydration? Yes___No___Why?__

EFFICIENCY Were resources available to the nurse and client maximized? Yes___No___Why?__ APPROPRIATENESS Were interventions appropriate to client situation? ( meaning age, health condition, etc.) Yes___No___Why?__ ACCEPTABILITY Were all interventions acceptable to the client? Yes___No___Why?__ ADEQUACY Were the number of interventions enough to solve the health problem? ___No___Why?__

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The client doesn t experience any changes in the sense of taste and smell except when she experiences ill-conditions.

OBJECTIVE: Sunken eyes Body weakness Lethargy Dry skin Dry mouth Active bowel sounds Temperature: 37.6 C Pulse Rate: 92 bpm Respiratory Rate: 33 cpm Weight: 12 kg