Añonuevo, Marie Joy R.

BSN - III

Name of patient: Baby Carla Bajih

Age: 9mos

Address: Batangas City

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS

INDEPENDENT

Subjective: Deficient fluid Short term - 1. Establish rapport to 1. To gain trust Short term goal.
volume related to After 2hrs of the client and and cooperation
“Napapadalas ang Bowel movement continous significant others. of the patient. After 2hours of
pagtae ng anak ko for 3-5 times a nursing care nursing intervention
kaya para siyang day. and proper and 2. Monitor and record the goal was
nauubusan ng tubig" proper health VS. successfully met as
2. To obtain evidenced by the
teaching the
(+) dry mucous 3. Provide proper baseline data.
patient will
membrane ventilation and cool •Decrease risk for
manifest: 3. To avoid other
environment. complication of fluid
(+)slightly sunken fluid losses volume deficit.
•Decrease risk
fonatanels 4. TSB done through
for excessive •The temperature
(+) poor skin turgor complicatioan of sweating. back in to the
fluid volume normal range.
(+)defecated 3x to a deficit. 4. To reduce
yellowish watery stool body temperature •Mother acquired
•Mother will proper knowledge
at approximatelt 5-6tsp have the proper 5. Health teaching done 5. To maintain regarding the
knowledge to the mother hydration status disease and
weight regarding the and avoiding understand the
disease and 6. Instructed to increase dehydration intervention of the
8kgs (upon oral fluid intake of the
know the proper problem.
admission) client. 6. To avoid
intervention of
the problem. reoccurence of Long term
6kgs(assessment) 7. Advised proper the disease.
hygiene of the client. After 2 days of
(+)pyrexia
7. To avoid continous nursing
Long term- 8. Adequate rest and exhausting the care anr proper
sleep should be patient, thus may health teaching the
After 2 days of provided. lead more on goal was met as
continous fluid loss. evidenced by
nursing care DEPENDENT:
and proper 8. To deliver •Normal bowel
9. IVF administered as
health teachings fluids accurately movement and
ordered. Maintain at
the client will at desired rate. moist mucous
proper regulation.
maintain fluid membrane and
volume at 9. An antibiotic good skin turgor
10. Medication given as
functional level kills / diminishes
prescribed. Penicillin G
as evidenced by the
400,000 every 6hours.
microorganism
•Normalized causing the
bowel disease and
movement. preventing
manifestation to
•Moist mucous occur.
membrane and
good skin
turgor.