Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
Subjective: Diarrhea After 4 hours Independent: Helps differentiate After 4 hours of
“ sige man sija related to of nursing Observe and record stool Individual disease and nursing
kalibang tapos presence of interventions, frequency, characteristics, Assesses severity of interventions, the
tubig ra ag bacteria the patient amount and precipitating episode. patient was able
mulugwa. will report factors. to report
Kahapon, Kalima reduction in reduction in
sija nalibang” as frequency of Promote bed rest. Rest decreases intestinal frequency of
verbalized by stools motility and reduces stools.
the SO. metabolic rate.

Identify foods and Avoiding intestinal

Objective:
fluids that precipitate Irritants promotes
Frequent
diarrhea. intestinal rest.
watery
stools.
Restart oral fluid Gradual consumption of
V/S taken as
intake gradually. liquids may prevent
follows: Encourage breastfeeding. cramping and recurrence of
T: 37.3
P: 139 diarrhea. Breastfeeding
R: 44 provides proper
nourishment
Collaborative: Decreases G.I
Administer medications motility orperistalsis and
As prescribed by the diminishes digestive
physician. secretions to relieve
cramping and diarrhea.

Patient’s Name: R. G. Age: 5 months old Sex: Male

CC: Diarrhea
 Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Subjective: Diarrhea After 4 hours Independent: Helps differentiate After 4 hours of
“Pirme man mag related to of nursing Observe and record stool Individual disease and nursing
tae-tae. Basa presence of interventions, frequency, characteristics, Assesses severity of interventions, the
raba karajaw ija bacteria the patient amount and precipitating episode. patient was able
tae” as will report factors. to report
verbalized by reduction in reduction in
the SO. frequency of Promote bed rest. Rest decreases intestinal frequency of
stools motility and reduces stools.
Objective: metabolic rate.
Frequent
Identify foods and Avoiding intestinal
watery
fluids that precipitate Irritants promotes
stools.
diarrhea. intestinal rest.
Always crying
V/S taken as
Restart oral fluid Gradual consumption of
follows:
intake gradually. liquids may prevent
T: 37.7
Encourage breastfeeding. cramping and recurrence of
P: 126
R: 46 diarrhea.
Collaborative: Decreases G.I
Administer medications motility or peristalsis and
As prescribed by the diminishes digestive
physician. secretions to relieve
cramping and diarrhea.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Risk for After 8 hours Assess skin routinely, to assess causative or After 8 hours
impaired skin of nursing moting moisture, color, contributing factors of duty, the SO
integrity related duty, the SO and elasticity. had demonstrate
to excretions, can Epidermis of infants and behaviors and
moisture demonstrate andle client gently very young children is thin techniques to
behaviors and and lacks subcutaneous prevent skin
techniques to depth breakdown.
prevent skin
breakdown.  Observe for reddened Reduces likelihood of
areas or skin rashes, and progression of skin
institute treatment breakdown.
immediately.

Maintain meticulous skin To prevent friction or

hygiene, using mild shear injury
nondetergent soap, drying
gently and thoroughly, and
lubricating with lotion

 Provide information to SO to promote wellness.

about the importance of
regular observation and
effective skin care in
preventing problems.
Signs of dehydration

 Little or lack of urine, or urine that is darker than usual

 Urinating less frequently than usual (fewer than 6 wet diapers a day for infants and 8 hours or more without urinating for children)
 Thirst (babies may show thirst by crying, being irritable and eager to drink when something is offered)
 Irritability
 Not eating as well as usual
 Weight loss
 Dry mouth
 No tears when crying
 In babies who are younger than 18 months old, sunken soft spots on the top of their heads
 Skin that isn't as springy or elastic as usual

Sleepiness