NURSING CARE PLAN

NAME OF PATIENT: MARKO LEE GUMABAO _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO_
AGE & GENDER OF PATIENT: 4 YEARS OLD/MALE _ WARD: GASTRO WARD _
DIAGNOSIS: T/C COMMUNITY ACQUIRED PNEUMONIA;
DATE: JANUARY 17, 2022 _
ACUTEGASTROENTERITIS WITH MODERATE DEHYDRATION_

NURSING SCIENTIFIC NURSING NURSING

CUES RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVES INTERVETION
Subjective/s: Risk for Deficient fluid Date: January 17, 2022 Independent Date: January 17,
- His mother Deficient Fluid volume is a state Shift: 7 AM – 3 PM o Monitor vital o To determine 2022
stated that he Volume or condition in signs. (cardiac if there’s any Shift: 7 AM – 3 PM
evidence by which the fluid Time: 3 PM rate, respiratory progress.
experienced rate and Time: 3 PM
diarrhea and diarrhea and output exceeds
temperature)
abdominal pain vomiting with a deficient fluid Short Term o Provide Tepid o To reduce
for last 3 days. sign and volume. It occurs Sponge Bath After 6 hours of
After 6 hours of body heat and
With symptoms of when water and (TSB) for it to cool nursing intervention
abdominal electrolytes are nursing intervention down.
approximately 10 the patient will be able the goal was met the
times episode of pain, lethargy, lost from the o Monitor, measure o To determine
patient displayed
dry lips, skin, body's normal to: and record intake any progress
vomiting and and output. and to provide normal range of vital
more than 10 and oral fluids. The o Displayed signs and reduce the
accurate fluid
episodes of mucosa, and gastrointestinal normal range of replacement amount of output.
diarrhea. sunken eyes tract is one of the vital signs. needed.
most common o Reduce the o Assess mucous o To determine
Objective/s: sources of fluid membrane and the level of
amount of
Weighs: 14 kg loss. Vomiting output. skin turgor. dehydration.
and diarrhea are Collaborative
Initial V/S: o To replace
all risk for fluid
- CR: 134 bpm o Administer IVF water and
volume
and medications fluid loss in
- RR: 30 cpm deficiency. such as the body. To
- T: 38.4°C (axilla) (Wayne, G.-RN, Paracetamol, reduce fever,
2021) ORS, and relieve
Patient is lethargic, Metoclopramid vomiting and
fussy, has dry lips, e order by the diarrhea and
prevent severe
skin and oral doctor.
mucosa, and has dehydration.
sunken eyes and
few tears.
DRUG STUDY #1
NAME OF PATIENT: MARKO LEE GUMABAO _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO_
AGE & GENDER OF PATIENT: 4 YEARS OLD/MALE _ WARD: GASTRO WARD _
DIAGNOSIS: T/C COMMUNITY ACQUIRED PNEUMONIA;
DATE: JANUARY 17, 2022 _
ACUTEGASTROENTERITIS WITH MODERATE DEHYDRATION_

NAME OF DRUG DOSE, MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING

(GENERIC AND ROUTE AND OF ACTION REACTION/ SIDE RESPONSIBILITIES
BRAND) FREQUENCY EFFECTS

Brand Name: 5 mg It blocks To relieve and Children under the age Most common Assess for
dopamine D2 prevent of 1 year can increase adverse effects: extrapyramidal
METOCLOPRAMIDE IV and serotonin vomiting and risk of extrapyramidal symptoms.
5-HT3 to increase the disorders. Diarrhea
Generic Name: PRN Assess for
receptors in muscle tone of Sedation (drowsy
-Reglan the lower gastrointestinal
or sleepy) complaints.
chemoreceptor esophageal
Classification: trigger zone sphincter Extrapyramidal
(CTZ) that (LES). symptoms
- Anti-emetic Agents
and Prokinetic Agents stimulate
vomiting and
nausea.
 DRUG STUDY #2
NAME OF PATIENT: MARKO LEE GUMABAO _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO_
AGE & GENDER OF PATIENT: 4 YEARS OLD/MALE _ WARD: GASTRO WARD _
DIAGNOSIS: T/C COMMUNITY ACQUIRED PNEUMONIA;
DATE: JANUARY 17, 2022 _
ACUTEGASTROENTERITIS WITH MODERATE DEHYDRATION_

NAME OF DRUG DOSE, MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING

(GENERIC AND ROUTE AND OF ACTION REACTION/ SIDE RESPONSIBILITIES
BRAND) FREQUENCY EFFECTS

Brand Name: Sachet It restores the To replace Hypersensitivity to Common adverse Assess Vital Signs
water and fluids and medicine and severe effects: especially cardiac
ORAL Oral electrolytes minerals lost dehydration/volume rate.
REHYDRATION lost in the in the body loss. Vomiting
SALTS (ORS) OD Assess and monitor
body due to and reduce the Dizziness
glucose's effect of the intake and
Generic Name: output.
capacity to dehydration. Tachycardia
Hydrite boost sodium Weakness
Classification: and fluid
absorption in Irritability/Restlessness
Oral Electrolyte the small
Mixture intestine
through a
cyclic AMP-
independent
process.