Nursing Care Plan.

Nursing Implementat Evaluation

Assessment Goals Nursing Intervention Rationale
Diagnosis ion

Subjective Fluid volume To maintain Monitor vital signs, record Postural hypotension is
Data: the normal changes in blood pressure on part of the hormone
Parents deficit related to fluid status changing position, the aldosterone deficiency due
complain that excessive of child strength of the peripheral  hiporolemia and decreased
baby is passing arteries. cardiac output as a result
loss stool. defecation. of a decrease in
cholesterol.

Objective Measure weight client

data:  Providing mind the need
Baby look dull for replacement fluid
and week. volume and effectiveness
of treatment, rapid weight
gain caused by fluid
retention and sodium
associated with treatment
strois.

Assess the patient's thirst, to identify the influence of

fatigue, rapid pulse, capillary  hypothermia and volume
refill elongated, poor skin needs replacement.
turgor, dry mucous
membranes, skin color and
temperature record.

 help reduce discomfort

caused from dehydration
Provide regular oral care and maintain mucous
membrane damage
 Nursing Implementat Evaluation
Assessment Goals Nursing Intervention Rationale
Diagnosis ion

Sub. Data -Take vital signs.  -Maintain the body -Now

Hyperthermia Reduce the
Patient temperature. Reduce the
related to body
Complains that body
infection as temperature
he is feeling -Provide Comfortable  -For provide rest temperature
manifested by (101f)
Increased body position . about (101 f)
elevated body
Temperature.
temperature
-Provide cold sponge bath (2- -Patient feels
Obj. Data  -For maintain the body
3 times) Comfortable.
By observing temperature
take vital sign
patient has -Given the advice wearing
fever. clean clothes.  -For prevent further any
infection.
-Because effected the
immune system by vital
inspection.
 Nursing Implementat Evaluation
Assessment Goals Nursing Intervention Rationale
Diagnosis ion

Sub. Data
-Assess the intake and output -To maintain nutrition .NOW
Chart. level.
Patients says Impaired nutrition Maintain Maintain the
that he has status less than the nutritional
suffer from body requirement nutritional balance.
-Provide good nutrition diet. -For giving nutrition diet.
loss of appetite related to balance.
inappropriate
feeding as
-Obtain dietary history -Defines the need for
Obj. Data manifested by
including likes or dislikes. nutritional education.
By observing regurgitation of
patient looks feeds.
very weak.

Sub. Data -Take vital signs.  -Maintain the body -Now

Hyperthermia Reduce the
Patient temperature. Reduce the
related to body
Complains that body
infection as temperature
he is feeling -Provide Comfortable  -For provide rest temperature
manifested by (101f)
Increased body position . about (101 f)
elevated body
Temperature.
temperature
-Provide cold sponge bath (2- -Patient feels
Obj. Data  -For maintain the body
3 times) Comfortable.
By observing temperature
take vital sign
patient has -Given the advice wearing
fever. clean clothes.  -For prevent further any
infection.
-Because effected the
immune system by vital
inspection.
Assessment Nursing Diagnosis Objective Nursing Intervention Evaluation
Deficit knowledge related to Patient will get adequate Reassess the knowledge Child’s family members got
therapeutic regimen. knowledge regarding level of the client to plan
adequate knowledge
Objective data: therapeutic regimen as the health education. regarding the therapeutic
evidenced by regimen as evidenced by
> Family members verbalization. Provide explanations verbalization.
asks frequently regarding the cause of
regarding drug edema to avoid anxiety in
regimen and patient.
prognosis.
Explain about the
importance of therapeutic
regimen to make her
understand about the
importance of drug
regimen.

Encourage her to
communicate with the
clients of same condition to
have exchange of feelings.