Nursing Care Plan

PROBLEM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Diarrhea Diarrhea After 5 hours Gradually add semisolids and  Semisolids and solids(crackers, yogurt, rice, Goal met:
related to of nursing solids(crackers, yogurt, rice, bananas, apple) that are stool former. Very After 5 hours of
presence of interventions, bananas, apple) Caution against cold and hot fluids can increase intestinal Nursing interventions, the
toxins as manifested by: the patient very hot or very cold fluids motility. patient was able to report
will report less diarrhea.
Increased less diarrhea Collection of Stool for observation Helps differentiate individual disease and
peristalsis. of its characteristics and record it Assesses severity of episode.

Excreted 5 loose
liquids stools in a day Promote bed rest. Rest decreases intestinal motility and
Reduces metabolic rate
V/S taken as
follows: Ingest clear liquids(fruit juices, To promote return to normal bowel
T: 36 C broth) functioning
P: 61
R: 19 Avoid foods that Foods that may precipitate gastric
Bp: 140/80 are oily, spicy and cramping.
caffeine.
And “Naapges nga
sumakit ti tyian ko” as Explain how to prevent  To prevent the ingestion of foreign bodies
verbalized by the patient transmission of infection(hand that could cause disease and to prevent the
washing, proper storing, cooking, re occurrence of diarrhea
and handling of foods)
Nursing Care Plan

PROBLEM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Multiple Risk for Infection related After 8 hrs of Instruct individual to ask all Prevents the transfer of harmful agents Goal met:
abrasions to multiple abrasions and nursing visitors and personnel to wash their towards the patient thus decreasing the After 8 hours of nursing
and laceration in the intervention, hands before approaching individual. chances of infection intervention, patient was
laceration in forehead patient will able to demonstrate no
the forehead demonstrate no Maintain sterile technique for  Prevents the cross-contamination or sign of infection.
sign of infection invasive procedures. bacterial colonization

 Change dressings as needed or  Prevents bacterial growth

Objective: indicated
Temperature 36.8 C
 Administer prophylactic antibiotics Prevents infection from occurring
Presence of multiple and immunizations as indicated
abrasions and 3-4 cm
laceration in the  Monitor V/S specially temperature The increase of temperature reflects the
forehead inflammatory/ infection process requiring
evaluation and treatment

Promote Fluid intake Increases the patient’s immune system