NURSING CARE PLAN

PRIORITIZATION OF NURSING DIAGNOSES

1st Priority: The patient is reportedly experiencing dehydration in relation to excessive elimination of
wet and foul-smelling stools. This nursing diagnosis must come first as it needs immediate solutions to
prevent the patient from experiencing more alarming conditions such as hypovolemic shock.

2nd Priority: This is prioritized second because fever or elevated body temperature is only a
compensatory response to eliminate the possible parasites that caused the infection. This should be
resolved as soon as possible to lessen any significant health complications. Also, if dehydration from the
first NCP will be solved then it may also be a factor for decreasing the temperature.

3rd Priority: This is placed last because the patient reported dizziness, and as the data shows the pulse
rate is elevated and the blood pressure is low. According to Deussen, 2007., an increase in the body core
temperature (hyperthermia) from approximately 36.5 to 39 degrees C causes a doubling of the cardiac
output. With both of the first two NCP being prioritized, it will solve the three nursing diagnoses in
almost a domino effect.

NCP #1 DEFICIENT FLUID VOLUME:

Assessment:

● Excessive elimination of stools, poor skin turgor, sunken eyes and dry mucous membranes.

Planning and Interventions:

● Focused on rehydrating the patient and educating the patient’s guardians/parents on how to
prevent the situation from worsening.

Example:

● Encouragement in increasing fluid intake by providing appealing liquids.

● Encouragement to eat foods with high fluid content, such as watermelon, grapes.
● Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at home.
○ ORS sachet: Open the sachet and pour the contents into 200 mL of water. Stir well until
all the powder has gone and the mixture is clear or just slightly cloudy.
○ ORS Made at home: Give the child a drink made with 6 level teaspoons of sugar and 1/2
level teaspoon of salt dissolved in 1 liter of clean water. Be very careful to mix the
correct amounts. Too much sugar can make the diarrhea worse. Too much salt can be
extremely harmful to the child. A child aged 2 years or older needs at least 1/2 to 1 whole
large (250-milliliter) cup of the ORS drink after each watery stool.

NCP #2 ACUTE PAIN:

Assessment:

● Pain Scale of 6/10

● Detection of pancytopenia and hepatosplenomegaly
● Grimace
 ● Irritability
● Restlessness
● Guarding behavior around abdomen

Planning and Interventions:

● Focused on reducing the patient’s pain scale from 6/10 to 3/10 and verbalizing methods on how
to do it.

Example:

● Encourage deep breathing exercises and provide diversional activities such as watching videos or
playing non-strenuously with toys.
● Administer paracetamol 7.5ml syrup q6h.

NCP #3 HYPERTHERMIA:

Assessment:

Temp na 39 degrees, irritability, general signs of weakness

Why number 2? Bcoz if in balance na ang fluid volume is it can regulate the temperature somehow, and
also if not acted upon immediately is it can lead to convulsions and serious brain injuries(42 degrees and
above can cause it)

Planning and Interventions:

Normal VS –Focused decreasing the body temp like loosening clothes and tepid sponge bath, and
administer paracetamol syrup to manage the fever, increase fluid intake,

Maintain no injury and convulsion–The patient is also irritable base sa assessment kaya we need to make
sure side rails are up since pedia patient naten, health education sa guradian of danger signs

Show decrease in chills, irritability and general weakness-promote stress free environment, loosen
clothing, tepid sponge bath, apply ice sa forehead axillary and groin the monitor the patient's response,
also administer paracetamol.

NCP #4 DECREASED CARDIAC OUTPUT:

Assessment:

low blood pressure of 85/90, tachycardia, tachypnea, low oxygen saturation, low blood levels of RBC, Hgb, Hct,
WBC, neutrophil and lymphocyte.

Why number 3? Bcoz high temperature can affect the cardiac output base kay Deussen
Why walang subjective data? Bcoz it is not sumthing that can be easily noticed by non medical worker
and also we need lab test to verify it such as low levels sa cbc which our patient has, pati low bp,low 02
stat, high rr and pr na only health personnels lang din alam kumuha.

Planning and Interventions:

Planning is centered sa mga easy modifiable na s/sx pero nagshoshow pa din ng improvement sa cardiac
output such levels of oxygen, pr, rr, bp. Not included agad ang blood levels since improvement ng blood
levels can be visible 3days -1week pa, pero if needed sa super baba ng blood levels is blood transfusion
na ang recommended.

Intervention: reposition the patient in semi fowler for better lung ecpansion hence facilitating breathing,
monitor vs for improvement or danger signs, monitor fluid intake since some patient cannot tolerate high
fluid intake and pwede magkaron ng presence of edema, encourage rest para di na tumaas rr and pr,
encourage b12 vitamins diet to help replenish low blood levels

Dependent: administer oxygen 2LPM facilitate breathing.