LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN

RELATED LEARNING EXPERIENCE

STUDENT NAME: SABADO, DIANA R. ROTATION: 5TH AREA: PEDIA WARD

CLINICAL INSTRUCTOR: GUERLY MANZANO-
YR LEVEL AND SEC: BSN II- LEWIN DATES:  NOV. 10,15,16,17,22 ACOSTA, MAN

PROBLEM: Impaired Verbal Communication DIAGNOSIS: Acute Gastroenteritis

PRIORITIZATION: Unclear speech DATE: November 10, 2021

NURSING
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Impaired Short-term Independent:  Patients may have Short-term:
Subjective:  The goal was
verbal goal: After 2-3  Maintain eye contact defect in field of
communication hours of with patient when vision or they may met. After 2-3
r/t speech intervention, speaking. Stand close, need to see the hours of
delayed as the client will within patient’s line of nurses’ face or lips intervention the
evidenced by be able to vision (generally to enhance their cause of the
unclear speech identify the midline). understanding of problem was
Objective: cause of the  Learn patient needs what is being identified.
problem. and pay attention to communicated. Long-term:
 Noticed that nonverbal cues.  The nurse should  For further
the patient Long-term  Assess set aside enough evaluation.
still has goal: After 7 language/communicati time to attend to
unclear days, the client on skills using all of the details of
speech will able to milestones checklist. patient care. Care
 The patient show Dependent: measures may
can’t say his improvement  Refer to the attending take longer to
name or age on his physician if something complete in the
 PROBLEM: Risk of imbalanced diet DIAGNOSIS: Acute Gastroenteritis
PRIORITIZATION: Malnutrition DATE: November 10, 2021

NURSING
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Risk of Short-term  Several factors
Subjective: Short-term: The goal
imbalanced goal: After Independent: may affect the
 The mother diet r/t  Assess patient’s ability patient’s was met. After 3-5 hours,
3-5 hours, the patient’s parent was
claimed that her malnutrition to obtain and use nutritional intake,
the patient’s able to learn and identify
son is a “picky as evidence essential nutrients. so it is necessary
parent will the prevention of the
eater” and often by being a be able to  Educate parents about to assess
prefers finger “picky eater” the possible accurately. risk of malnutrition or
learn and imbalance diet.
foods like and less complications if risk  To treat upset
identify on Long-term: The goal
chicken nuggets intake of fruit malnutrition stomach and
how to was partially met. After 2
and hotdogs. and neglected. induce better
prevent the
 The mother vegetables  Note real, exact appetite for the
weeks, the patient was
risk of able to improved
claimed that her weight; do not patient.
malnutrition nutrition and need for
son is not fond of estimate.  These
or further evaluation.
fruits and Dependent: anthropomorphic
imbalance
vegetables and  Recommend to start assessments are
diet.
only consumes diet for age or BRAT vital that they
Long-term
formula milk at diet as tolerated. need to be
goal: After 2
times. Collaborative: accurate. These
weeks, the
Objective: patient will  Inquire with a will be used as
 Height- 37.5 be able to dietician for a more basis for caloric
inches improve thorough evaluation and nutrient
 Weight- 15 kg nutrition and food preparation requirements.
and gain for a nutritionally  Serves as a guide
weight balanced meal. for parents when
toward ideal preparing food for
weight for the patient.
height and  Dieticians have a
age. broader