NURSING CARE PLAN

(NCP)
NURSING CARE PLAN Document QF-CN-25 Revision 1
Code Number
(NCP)
Effectivity August 17, 2018

NAME/ INITIALS OF PATIENT:___RUS__________________________________________ AGE:______5_____ SEX: _____F_____ STATUS: ____Single_____

ADDRESS: _Bugias, Benguet__________________________________________________ HOSPITAL: ________BeGH_________ WARD: ____Pedia_______
PRINCIPAL MEDICAL DIAGNOSIS: _Acute gastroenteritis with moderate dehydration__________________________________________________________
NURSING CARE PLAN DEVSED BY:_Ira G. Delos Santos_______________________________ YEAR AND SECTION:______2B______ GROUP______1_______
SCORING IMPLEMENTATION
CRITERIA VL L H VH
NURSING ORDERS / APPROACHES RATIONALE
Content
Complete
Assessment
Parameters
Nursing
Diagnosis
Short-term
Outcome
Long-term
Outcome
Nursing
Orders
Rationales
Actual
outcome
TOTAL SCORE

VH – Very High
H – High
L – Low
VL – Very Low

Rated by:

Date: __________________

Conforme:
ACTUAL OUTCOME DATE AND TIME RESOLVED
Date:__________________

DATE AND TIME
11 PM
March 24, 2020
ASSESSMET PARAMETERS
S> “Okay na yong ubo niya pero
nagtatae siya at nagsusuka” as
verbalized by the mother
O>Hyperactive bowel sounds
>Dry oral mucous membrane
>5 times loose liquid stools a day
>Poor skin turgor
>Decreased urine output: 10mL/hr
>Tachycardia
>Vitals signs taken as follows:
PR: 133
RR: 29
Temp: 27.3
O2Sast: 98%
NURSING CARE PLAN Document QF-CN-25 Revision 1
(NCP) Code Number
Effectivity August 17, 2018
NURSING DIAGNOSIS SHORT – TERM AND LONG – TERM OUTCOMES
After 5 to 6 hours of nursing intervention, will After 4 to 5 days of nursing intervention,
be able to manifest increased fluid volume will be able to maintain fluid volume at
functional level.
IMPLEMENTATION
NURSING ORDERS / APPROACHES RATIONALE
Assessment
> Assess skin turgor and oral mucous membrane for signs of >Signs of dehydration are detected through skin.
dehydration
>Note presence of nausea, vomiting and fever >These factors influence intake, fluid needs and route of replacement.
>Obtain history and observe stools for volume, frequency, >For baseline data. Establishing a database of history aids accurate and
characteristics and predisposing factors individualized care for each patient
Treatment
>Regulate IVF properly and maintain flow rate >To promote hydration
>Offer adequate oral fluid >To minimize mucosal drying. Oral fluid replacement is indicated for
fluid deficit and is a cost-effective method for replacement treatment.
>Provide measures to prevent excessive electrolyte loss >Fluid losses from diarrhea should be concomitantly treated with
antidiarrheal medications as prescribed
>Aid if he or she is unable to eat without assistance and encourage >Dehydration patients may be weak and unable to meet prescribed
significant others to assist with feedings, as necessary intake independently
Educative
>Instruct significant others to hand hygiene at each care times >To prevent transmission of infection
>Encourage to drink bountiful amounts of fluid as tolerated or as based >Promotes hydration
on individual needs
>Enumerate interventions to prevent or minimize future episodes of >Patient needs to understand the value of drinking extra fluid during
dehydration diarrhea
>Emphasize the relevance of maintaining proper nutrition and >Increasing the patient’s knowledge level will assist in preventing and
managing the problem.
hydration
ACTUAL OUTCOME DATE AND TIME RESOLVED
Goal met. After 6 hours of nursing intervention, able to manifest increased fluid volume as evidenced by 5 AM
increased urine output to 40mL/hr, moist oral mucous membrane and with good skin turgor March 25, 2020
Deficient fluid volume related to nausea, vomiting and diarrhea secondary to acute gastroenteritis.