PROBLEM NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Nutrition After 3 days  Measure  This will After 3 days
“nagsusuka imbalanced of nursing client accurately of nursing
ang anak ko” less than intervention weight.  monitor the intervention
as body the will be  Monitor and response to the client
verbalized requirements able to record the therapy. achieve to
by the related to maintain the number of maintain the
 These data
mother. vomiting. normal usual vomiting, normal usual
will help
weight. amount and weight.
in
OBJECTIVE: frequency. initiating
Pale
 Provide nursing
conjunctiva
parenteral actions and
and mucus
fluids, as subsequent
membrane
ordered treatment.
V/S taken as
follows:  To ensure
T:36.5 adequate
P:100 fluid and
R: 25 electrolyte
levels.
PROBLEM NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for After 2 days  Evaluate  Defecation After 2 days
“nagtatae Fluid of nursing pattern of pattern will of nursing
ang anak Volume intervention defecation promote intervention
ko” as Deficit Client will  Assess for immediate Client will
verbalized related to pass soft, abdominal pain, treatment. pass soft,
by the Bacterial formed stool abdominal  These formed stool
mother viral or no more than cramping, assessment no more than
OBJECTIVE: parasitic 3 times a hyperactive findings are 3 times a
Crying infections day. bowel sounds, commonly day.
Loose as frequency, connected with
stools evidenced urgency, and diarrhea. If
Increase by loose loose stools. gastroenteritis
bowel stool
 Submit client’s involves the
sounds large
stool for
V/S taken intestine, the
culture
as follows: colon is not
T:36.7 able to absorb
P:90 water and the
R:30 client’s stool
is very watery.
A culture is a
test to detect
which
causative
organisms
cause an
infection.
PROBLEM NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Hyperthermia After 8  Assess and  Temperature After 8
“mainit and related to hours of monitor 38.9ᴼC – 41ᴼC hours of
anak ko infection as nursing client’s may suggest nursing
tapos di evidenced by intervention temperature and acute intervention
tumitigil 38.9 the note for infectious the
sa pag iyak hyperthermia presence of disease hyperthermia
at ayaw mag will subside chills/ profuse process. A subside
gatas” as diaphoresis; sustained
verbalized also note for fever may be
by the degree and due to
mother pattern of pneumonia or
OBJECTIVE: occurrence. typhoid fever
Flushed  Apply tepid while a
skin with sponge bath. remittent
body fever may be
 Encourage
client to due to
V/S taken pulmonary
increase fluid
as follows infections;
intake
T:38.9ᴼC and an
R:60 intermittent
Pulse: 120 fever may be
chills caused by
Profuse sepsis or
diaphoresis tuberculosis.
 It could
help in
reducing
hyperthermia;
avoid using
alcohol and
iced water
which may
even produce
chills and
increase
client’s
temperature
 Water
regulates
body
temperature.