VIII.

NURSING CARE PROCESS

NURSING SCIENTIFIC
ASSESSMENT PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Elevated Body Gastroenteritis, also After 30 Independent: The goal was
“Nilalagnat ang Temperature known as infectious minutes, the 1. Identified underlying cause. 1. To assess causative or partially met.
anak ko.” as related to diarrhea, is patient’s body distributing factors.
verbalized by the inflammation inflammation of the temperature will 2. Monitored body temperature. The patient’s
mother of the gastrointestinal tract subside to 37°C. 2. To evaluate effects or body temperature
gastroinstestin that involves the degree of hyperthermia. subsided to
Objective: al tract stomach and small 3. Noted presence or absence of 37.7°C.
 Axillary intestine. Symptoms sweating as body attempts to 3. Evaporation is
Temp. 38.5°C may include diarrhea, increase heat loss by decreased by
 Warm to touch vomiting and evaporation, conduction and environmental factors
 Teary eyed abdominal pain. Fever, diffusion. of high humidity and
 Diaphoretic lack of energy and high ambient
 Irritable dehydration may also temperature as well as
 Restless occur. This typically body factors producing
lasts less than two loss of ability to sweat
weeks and it is not or sweat gland
related to influenza dysfunction.
though it has been
called the stomach flu. 4. Promoted surface cooling by 4. To assist with measures
means of tepid sponge bath. to reduce body
temperature, restore
Reference: normal body/organ
Porth, C.M. function.
(2005).Essential of 5. Encouraged the mother to
Pathophysiology: increase oral fluid intake of 5. To prevent dehydration.
Concepts of altered his child.
health states. 2nd
6. Emphasized to the mother 6. This measure conserves
edition. pp. 89-90, 656
the importance of adequate patient’s energy
rest periods for his child.
Dependent:
1. Administered Paracetamol 80 1. To provide
mg TIV q4 for temp > 37. 8 pharmacological
C management (reduces
fever)

Interdependent:
1. Monitored laboratory studies
such as WBC count, electrolytes
and urinalysis.
1. To determine the
effectiveness of
treatment/management
rendered to the patient

Reference:
Doenges M.E., Moorhouse
M.F., and Murr A.C.
(2006). Nurse’s Pocket
Guide: Diagnoses,
prioritized interventions
and rationales, F.A. Davis
Company, 10th edition pp.
299-302