NURSING CARE PLAN

Name: Angelica Villante AGE: 13 CC: Persistent vomiting

Assessment
Subjective Data: Limang beses na siyang nagsuka. Si Huri ngani gulpi ng maray si naisuka niya Objective Data: Vomited 5 x Febrile- 39 Dry skin and mucous membrane Poor skin turgor VS= T-39 P-102 R-32 BP-110/80

Nursing Diagnosis
Deficient fluid volume r/t loss of fluids and electrolytes as manifested by vomiting

Rationale
Dehydration is a common body fluid disturbance in infants and children and occurs, whenever the total output of fluid exceeds the total intake, regardless of the cause. Dehydration may result from a number of diseases that cause insensible losses through the skin and respiratory tract, through increased renal excretion, and through GI tract. Although dehydration can result from lack f oral intake, more often it is a result of abnormal losses such as those occurs in vomiting and diarrhea.

Outcome Criteria
After 6 hours of nursing intervention the patients will be able to: Exhibit moist mucous membrane and good skin turgor Retain feeding without experiencing vomiting.

Nursing Intervention
DEPENDENT: Assess skin turgor Monitor VS

Rationale
Serves as an evidence of dehydration Increased temperature and RR contribute to fluid loss. A weak, thread pulse and drop in blood pressure indicate dehydration Replace fluid loss without causing further GI irritation Infusing too rapidly or too slowly can lead to fluid imbalance

Evaluation
Goals partially Met: After 6 hrs of NSG Intervention the patient: The patient had moist mucous membrane but still has a poor skin turgor. She was also able to eat small amt of crackers and able to sip water and Gatorade.

When vomiting decreases, offer a sip of water Monitor IV