URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: Alipio, Rosemarie T. Year Level and Group: BSN-III

Affiliating Agency/Area: Month/Year of Exposure:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence
“I’m having lbm  Assess vital signs  Provides baseline for After 8 hrs. of nursing
8x a day and Fluid Volume Deficit After 8 hrs of nursing assessing and intervention, the patient is able to
vomiting 4x a day intervention, evaluating maintain fluid volume at a
related to active fluid
for the past two interventions functional level
days after eating volume loss (e.g patient will be able to
raw tuna from a diarrhea) maintain fluid volume at a  Note physical signs of  Predictors of fluid
Japanese functional level dehydration GOALS MET
balance that should
restaurant” as
be in client’s usual
verbalized by the
patient range in a healthy
Objective: INFERENCE Long Term Goal: state. Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence
(Diagram Form) After 3 days of nursing
 sunken After 3 days of nursing  Assess the volume and  Vomiting is associated intervention the patient is able to
Intestinal fluid output intervention, the patient frequency of vomiting. with fluid loss. maintain adequate fluid volume
eyelids overwhelms the will maintain adequate as evidence by moist mucous
 very absorptive capacity of fluid volume as evidence  Assess the client’s skin  A loss of interstitial fluid membranes, good skin turgor,
the GI tract by moist mucous turgor and mucous causes the loss of skin and capillary refill.
dry membranes for signs of
membranes, good skin turgor. Assessment of the
skin dehydration. skin turgor in adults is GOAL MET
turgor, and capillary refill.
 Lack of less accurate since their
skin normally loses its
energy damage to the villous
elasticity. Therefore the
delaye brush border of the
skin turgor assessed over
intestine
d skin the sternum in the
forehead is best. Several
turgor.
longitudinal furrows and
Vital Signs taken as coating may be noted
follows: malabsorption of along the tongue.
BP: 90/60 intestinal contents
CR: 115  Educative
RR: 25
Temp: 37.8.
leading to an osmotic
diarrhea
release of toxins that
bind to specific
enterocyte receptors
Fluid Volume Deficit
related to active fluid
volume loss (e.g.
diarrhea)
 Increased fluid intake
 Encourage increase
fluid intake of 1.5 to
2.5 liters/24 hour
plus 200 ml for each
loose stool in adults
unless
contraindicated.
 Fluid deficit can cause a
 Encourage regular
oral hygiene.
 The client with
 Instruct the client to
monitor weight daily
and consistently with
the same scale,
preferably at the
same time of the
day, and wearing the
same amount of
clothing.
replaces fluid lost in the
liquid stool. Being
creative in selecting fluid
sources (e.g., flavored
gelatin, frozen juice bars,
sports drink) can facilitate
fluid replacement. Oral
hydrating solutions (e.g.,
Rehydrate) can be
considered as needed.
dry, sticky mouth.
Attention to mouth care
promotes interest in
drinking and reduces the
discomfort of dry mucous
membranes.
gastroenteritis may
experience weight loss
from fluid loss with
diarrhea and vomiting.
Instruction facilitates
accurate measurement
and assessment provides
useful data for
comparisons and helps in
following trends.

 Enough knowledge aids

 Educate patient the patient to take part in
about possible cause his or her plan of care
and effect of fluid
losses or decreased
fluid intake.

Dependent:  These drugs will reduce

 Administer vomiting and the risk for
antiemetic fluid volume deficit.
medications as
ordered
 Fluids are necessary to
 Administer parenteral maintain hydration
fluids as prescribed. status. Determination of
 Consider the need for the type and amount of
an IV fluid challenge fluid to be replaced and
with immediate infusion rates will vary
infusion of fluids for depending on clinical
patients with status.
abnormal vital signs.

Interdependent/Collaborative
 A central venous line
 Assist the physician with allows fluids to be infused
insertion of central centrally and for
venous line and arterial monitoring of CVP and
line, as indicated. fluid status. An arterial
line allows for the
continuous monitoring of
BP.

Checked by: _________________________________ Date: ____________________

 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

DRUG STUDY
Name of Student: ____Alipio, Rosemarie T.___ Year Level and Group: BSN III-BLK5

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure:

DRUG CLASSIFICATION INDICATION SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES

Teaching points

Generic Name: Used to treat a variety  Anaerobic  Dizziness  GI disturbances  Take full course of drug therapy; take the
drug with food if GI upset occurs.
of infections. It e.g. nausea,
Metronidazole Bacterial  headache  Do not drink alcohol (beverages or
belongs to a class of Infections. unpleasant preparations containing alcohol, cough
antibiotics known as  stomach upset metallic taste, syrups); severe reactions may occur.
Loading dose: 15  Your urine may be a darker color than usual;
vomiting,
Brand Name:
nitroimidazoles. It mg/kg IV; not to  nausea this is expected.
works by stopping the diarrhoea or  Refrain from sexual intercourse during
exceed 4 g/day.  Vomiting constipation. treatment for trichomoniasis, unless partner
Flagyl growth of bacteria wears a condom.
 Sexually Furred tongue, Apply the topical preparation by cleansing
and protozoa. This  loss of appetite glossitis, and

Dosage: Transmitted the area and then rubbing a thin film into
antibiotic only treats the affected area. Avoid contact with the
Disease.  diarrhea stomatitis due
 Capsule- bacterial and to overgrowth eyes. Cosmetics may be applied to the area
Prevention after application.
375mg protozoal infections.  constipation, or of Candida.  You may experience these side effects: Dry
 Tablet- following sexual mouth with strange metallic taste (frequent
metallic taste in Rarely,
assault mouth care, sucking sugarless candies may
250mg or antibiotic- help); nausea, vomiting, diarrhea (eat
 Bacterial your mouth associated
500mg frequent small meals).
Vaginosis. colitis.  Report severe GI upset, dizziness, unusual
may occur
Route: fatigue or weakness, fever, chills.
Nonpregnant Weakness,
PO, IV, TOPICAL women.  fevers dizziness,
ataxia,
 Colorectal  pain with
Frequency: headache,
Surgical urination drowsiness,
The capsule dose is Infection. insomnia,
375 mg 2 times a  Trichomoniasis.  mouth sores, changes in
mood or mental
day for 7 days.  Amebiasis.  tingling or state.
 Giardiasis (Off- pricking Numbness or
label) sensations that tingling in the
may become extremities,
 Gardnerella
permanent, epileptiform
Infection. seizures (high
 brain disease, doses or
and prolonged
treatment).
 seizures. Transient
Serious but unlikely leucopenia and
thrombocytope
side effects of Flagyl
nia.
include:
Hypersensitivity
 unsteadiness, reactions.
Urethral
 seizures, discomfort and
darkening of
 mood changes,
urine. Raised
 numbness or liver enzyme
tingling of the values,
hands or feet, cholestatic
and hepatitis,
jaundice.
 Painful Thrombophlebi
urination. tis (IV).
 Potentially
 Fatal:
Anaphylaxis.

Clinical Instructor’s Name and Signature

 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

Name: Alipio Rosemarie T.

FDAR
DATE/TIME FOCUS NURSES NOTES
05/01/2021 Vomiting D: A male 24 year old patient went to the
ER with the complaint of severe lbm and
vomiting. Appears sunken eyelids, very
dry skin, lack of energy and delayed skin
turgor with the vital signs of:

BP: 90/60
CR: 115
RR: 25

A:
• Assess vital signs

• Note physical signs of dehydration

• Assess the volume and frequency of

vomiting.

• Assess the client’s skin turgor and

mucous membranes for signs of
dehydration.

R:
Seen the patient is able to maintain
adequate fluid volume as evidence by
moist mucous membranes, good skin
turgor, and capillary refill.