Name of Student: Florianne Jamie Lee S Oraa NURSING CARE PLAN Section and group number: BSN 3-A G4

Name of CI: Ms. Kimberly Anne Villarosa RN, MN Area of Exposure: Medical Ward

Assessment Nursing (Rationale) Desired Nursing Justification Evaluation

Cues Diagnosis Pathophysiologi Outcome Intervention
c/ Schematic
Diagram

Subjective: -Deficient volume Predisposing After 3-5 days 1.1 Assess the 1.1 To be updated After 5 hours of
“Kagapon pa ako related to Factors: of nursing patient’s vital on the client's Nursing
ga lupot kag ga moderate -Male intervention the signs closely. health status and Intervention, the
sige dehydration as -18 y/o client will be: monitor her client was able to:
suka”verbalized evidenced by 1.2 Assess for progress.
by the patient continuous Precipitating Short Term signs of
1. Manifested lower
vomiting and Factors: Goal: dehydration such 1.2 To assess
body temperature to
diarrhea. - Deficient fluid as dry mouth, and elevated body
37.0 C
Objective: volume due to 1.The patient’s sunken eyes. temperature
-GOAL MET
NANDA continuous vomiting temperature will increases the
Received awake Definition: and defecation lower down to 1.3 Maintain metabolic rate,
2.Did not show
and responsive to A state or 37.5 C adequate fluid hence increases
further signs of
both verbal and condition where intake as the insensible
dehydration.
painful stimuli. the fluid output intestinal fluid output 2. The patient’s tolerated. fluid loss.
-GOAL MET
exceeds the fluid overwhelms the vital sign will be
Chief complaint: intake. It occurs absorptive capacity stable. 1.4 Instruct the 1.3 To prevent
3. Continued
Continuous when the body of the GI tract client to monitor dehydration;
adequate liquid
vomiting, loose loses both water 3. Increase of weight daily and Avoid fluid
intake as he was
bowel movement, and electrolytes | fluid intake. consistently with overload because
being treated.
and fever from the ECF in the same scale, of the risk of
-GOAL MET
similar damage to the After 7 days of preferably at the cerebral edema.
proportions. villous brush border nursing same time of the
Health History: of the intestine. intervention the day, and wearing 1.4 To facilitate
4. Constantly
client will be: the same amount accurate
He is a non- checking of weight
| of clothing. measurement and
smoker, and and taking down
assessment
drinks alcohol in noted for accurate
malabsorption of Long Term 1.5 Administer provides useful
moderation. With measurement and
intestinal contents Goal: antiemetic data for
a history of assessment
medications as comparisons and
hypertension on - GOAL MET
1. The patient’s ordered. helps in following
 temperature will trends. 5. Reduced
the father side | go back to vomiting was
and diabetes on normal. 1.5 To reduce experienced by the
the mother side. leading to an vomiting and the patient.
No history of osmotic diarrhea 2. The patient’s risk for fluid -GOAL MET
previous | fluid level will volume deficit.
admission. return back to
release of toxins normal.
that bind to specific
enterocyte receptors 3. Normal
History of the
Output of the
present Illness
| patient.
-The patient had
lunch at a release of chloride 4. The patient
restaurant and on ions into the will be able to
the same day he intestinal lumen, perform
experienced leading to secretory postpartum care
epigastric pain diarrhea. at home. .
and passed out a
watery stool.

-He took the

Loperamide 1
capsule but after
a few hours he
defecated again
to a watery stool
and was vomiting.

T: 39C
P: 138bpm
R: 33breaths per
minute
BP: 120/100
Pain Scale: 3/10

Strength:
-Supportive
Family
- Faith in God
-Optimistic

Weaknesses:
-Financially
unstable
-Stressful
environment