Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Subjective: Deficient Fluid Entry of Short Term: Independent: Short Term Goal:
“Madalas kasi ang Volume r/t Profuse Microorganisms on After 2hrs of  Established To gain trust and
pagtatae ng baby ko Bowel Movement the GI tract continuous nursing rapport to the confidence GOAL
kaya para siyang for 3-5 times a day care and proper client and SUCCESSFULLY
nauubusan ng tubig” secondary to Inflammation process health teachings the significant others MET
-As stated by the Inflammation of occurs patient will manifest:  Monitored and To obtain baseline After 2hrs of
mother the stomach and  Decrease risk for recorded v/s data continuous nursing
intestine Digestive and complications of  Provide proper  To avoid other fluid care and proper
Absorptive Fluid volume ventilation and loses through health teachings the
malfunction deficit cool environment excessive sweating. patient manifested:
 Significant others  Decreased risk
Objective: Excessive gas will have the Health Teachings for
 (+) dry mucous formation proper knowledge done to the S.O.: complications of
membrane regarding the  Instructed to Inc. To maintain Fluid volume
 (+) slightly sunken GI distention disease. Oral Fluid intake hydration status, thus, deficit
fontanels  Significant others of the client avoiding dehydration  Significant
 With fair skin turgor Increase Peristaltic will know the  Advised proper To avoid others acquired
 vaguely weak in Movement proper hygiene of the reoccurrence of the proper
appearance intervention of client disease knowledge
 Defecated 3x to a Mild-moderate the problem.  Adequate rest To avoid exhausting regarding the
yellowish watery Diarrhea and sleep should the patient, this may disease.
stool at Long Term: be provided lead more on fluid  Significant
approximately 1- Fluid Imbalance After 2 days of loss. others
3tsp. continuous nursing Collaborative: understand the
 On Breastfeeding Fluid Volume Deficit care and proper  IVF administered To deliver fluids intervention of
with good sucking health teachings the as ordered. accurately at desired the problem.
ability client will maintain Maintained at rates.
 Weight fluid volume at proper regulation Long Term:
-8kgs. (upon functional level as  Medications given An antibiotic Still on further
admission) evidenced by: as prescribed: kills/diminishes the Evaluation.
-6kgs. (upon  Normalized Bowel -Pen G 400,000 microorganisms
assessment) Movement TIV every 6 hrs. causing the disease,
 Moist mucous thus, preventing
membrane and manifestation to
good skin turgor. occur.
Name of Patient: M.G.V Student Nurse: EBEN EZAR H. DELA CRUZ
Age: 9mos. SMU-SN
Diagnosis: AGE with some signs of DHN