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  • Cues Nursing Diagnosis Scientific Rationale Goal Intervention Plan Rationale Evaluation

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    jay new chua
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    The patient was experiencing frequent loose watery stool and vomiting, leading to fluid volume deficit and dehydration as evidenced by slightly sunken eyeballs and low blood pressure and heart rate. This also caused nutritional imbalance due to inability to eat properly. There was also a risk for increased body temperature due to potential infection from diarrhea. The nursing care plan was to replenish fluids and electrolytes orally, monitor intake and output, implement a soft, low-fiber diet with frequent small meals, and monitor vital signs and provide warm compression and antipyretics to prevent fever. The goals of this plan were to maintain fluid and electrolyte balance, meet nutritional needs, and prevent increased body temperature.

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    The patient was experiencing frequent loose watery stool and vomiting, leading to fluid volume deficit and dehydration as evidenced by slightly sunken eyeballs and low blood pressure and heart rate. This also caused nutritional imbalance due to inability to eat properly. There was also a risk for increased body temperature due to potential infection from diarrhea. The nursing care plan was to replenish fluids and electrolytes orally, monitor intake and output, implement a soft, low-fiber diet with frequent small meals, and monitor vital signs and provide warm compression and antipyretics to prevent fever. The goals of this plan were to maintain fluid and electrolyte balance, meet nutritional needs, and prevent increased body temperature.

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    28 views2 pages

    Cues Nursing Diagnosis Scientific Rationale Goal Intervention Plan Rationale Evaluation

    Uploaded by

    jay new chua
    The patient was experiencing frequent loose watery stool and vomiting, leading to fluid volume deficit and dehydration as evidenced by slightly sunken eyeballs and low blood pressure and heart rate. This also caused nutritional imbalance due to inability to eat properly. There was also a risk for increased body temperature due to potential infection from diarrhea. The nursing care plan was to replenish fluids and electrolytes orally, monitor intake and output, implement a soft, low-fiber diet with frequent small meals, and monitor vital signs and provide warm compression and antipyretics to prevent fever. The goals of this plan were to maintain fluid and electrolyte balance, meet nutritional needs, and prevent increased body temperature.

    Copyright:

    © All Rights Reserved
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    of 2

    CUES

    Subjective:
    sige iya pag sinuka tas uro.
    may ada oras han 12am
    kaagahun nagsisinuka hiya tas
    uro.
    As verbalized by the patients
    mother.

    NURSING
    DIAGNOSIS
    1. Deficient fluid
    volume related to
    excessive fluid
    loss through the
    frequent loose
    watery stool and
    vomit.

    Objective:
    Slightly sunken
    eyeballs
    BP:100/60mmhg
    HR:136cpm
    RR:24bpm
    Temp:36.7c
    Wt.: 18.8kg
    2. Imbalanced
    Nutrition related
    to vomiting and

    SCIENTIFIC
    RATIONALE
    Rapid propulsion of
    intestinal contents
    through the small
    bowels may lead to a
    serious fluid volume
    deficit. The body
    would want to expel
    the foreign objects as
    much as possible thus
    it doesnt undergo its
    normal speed, with
    that, the digestive
    system organs are not
    able to absorb the
    excess fluids that are
    usually absorbed by
    the body.

    GOAL
    o

    After nursing
    action for 3x24
    hours, fluid and
    electrolyte
    balance is
    maintained to the
    fullest.

    INTERVENTION
    PLAN

    RATIONALE

    1) Encourage the
    patient to drink lots of
    water, 2-3L/day

    Replacing the lost


    electrolytes
    orally.

    2) Monitor intake and


    output

    To provide early
    detection of fluid
    imbalance and
    monitor the
    progress of
    treatment.

    EVALUATION
    After nursing
    action for 3x24
    hours, the
    patients vital
    signs are within
    the normal. The
    eyes are not
    sunk and the
    crown is not
    concave.
    Consistency of
    the bowel
    movement is
    soft, frequency
    1 time/day

    Patients
    nutritional needs
    can be met.

    1) Discuss and explain


    the restriction diet.

    High fiber, water


    is too hot or too
    cold can stimulate
    and irritate
    stomach and
    intestinal tract

    2) feed little and often


    frequency

    To stimulate
    appetite

    3) Give the patient time


    to rest.

    To reduce
    excessive energy
    consumption.

    Increase in
    appetite

    3. Risk for
    imbalanced Body
    temperature
    related to the
    process of
    infection
    secondary to
    diarrhea.

    After making
    maintenance
    action performed
    for 3x24 hours,
    there was no
    increase in Body
    temperature.

    1) Monitor vital signs


    every 4 hours.

    2) Give warm
    compression.

    3) Collaboration of
    antipyretic drugs.

    PATIENTS NAME: LERIOS, LANCE

    For early
    detection of
    abnormal changes
    in body function.
    Resulting in
    evaporation
    which reduces
    heat.
    Lower the fever
    and healing
    process.

    STUDENTs NAME: NEW CHUA , CEASAR JAY T.

    Body
    temperature is
    within the
    normal range
    (36- 37.5 )

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