SALARDA, RYA SHEEN T.

BSN4 C
Patient Name: Durano, Aireen E.
Age & Sex: 40 years old, Female
Physician: Dr. Gayao
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Deficient fluid Short Term Goal: Assess the client’s A loss of interstitial Short Term Goal:
“Katong nag sukaha volume r/t active fluid After 12 hours of skin turgor and fluid causes the loss of After 12 hours of
ko gahapon, dili man volume loss. nursing intervention, mucous membranes skin turgor. nursing intervention,
to sakit akong tiyan, the patient will be for signs of Assessment of the skin the patient was
ika-7 lang jud ko nag relieve from pain, and dehydration. turgor in adults is less relieved from pain,
suka munang nagpa fluid and blood accurate since their and patient’s fluid and
admit nalang ko aron volume will return skin normally loses its blood volume return
ma siguro ug unsay normal. elasticity. Therefore to normal as
hinungdan”, as the skin turgor evidenced by stable
verbalized by the assessed over the vital signs.
patent. sternum in the
forehead is best.
Objective: Several longitudinal
 Good Skin Turgor furrows and coating
 Cool & Clammy may be noted along
Skin the tongue.
V/S: Assess the volume and Vomiting is associated
 BP: 110/70 frequency of vomiting. with fluid loss.
mmHg
 PR: 110bpm Assess the consistency Gastroenteritis is
 RR: 19bpm and number of bowel associated with an
 T: 36.3 C movements. increased frequency of
 SpO2: 99% very loose or watery
bowel movements.
The inflammation in
the large intestine
limits the colon’s
ability to absorb water,
leading to fluid
volume deficit.
Assess the color and A decrease in urine
amount of urine. volume and
concentrated urine, as
evidenced by a darker
urine color, denotes
fluid deficit.
Assess the client’s PR A reduction in
and BP. circulating blood
volume can cause
hypotension and
tachycardia. The
change in HR is a
compensatory
mechanism to
maintain cardiac
output. Usually, the
pulse is weak and may
be irregular if
electrolyte imbalance
also occurs.
Hypotension is evident
in hypovolemia.
Assess the client’s Fever that occurs with
temperature. gastroenteritis
increases fluid loss
through perspiration
and increased
respiration.
Encourage regular oral Fluid deficit can cause
hygiene. a dry, sticky mouth.
Attention to mouth
care promotes interest
in drinking and
reduces the discomfort
of dry mucous
membranes.
Encourage increase Increased fluid intake
fluid intake of 1.5 to
replaces fluid lost in
2.5 liters/24 hour plus
the liquid stool. Being
200 ml for each loose
creative in selecting
stool in adults unless
fluid sources (e.g.,
contraindicated. flavored gelatin,
frozen juice bars,
sports drink) can
facilitate fluid
replacement. Oral
hydrating solutions
(e.g., Rehydrate) can
be considered as
needed.
COLLABORATIVE: COLLABORATIVE:
Administer To relieve the painful
Simethicone 40 mg 2 symptoms of too much
tabs gas in the stomach and
intestines.
Administer To treat indigestion,
Esomeprazole 40 mg heartburn and acid
NTT reflux, and gastro-
oesophageal reflux
disease (GORD) – a
condition which
means you keep
getting acid reflux.
Prevent stomach
ulcers.
SALARDA, RYA SHEEN T. BSN4 C
Patient Name: Durano, Aireen E.
Age & Sex: 40 years old, Female
Physician: Dr. Gayao
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Deficient knowledge After 12 hours of Assess client’s Clients who After 12 hours of
“Ngano diay ni r/t new disorder and nursing intervention knowledge of experience diarrhea nursing intervention,
Ma’am? Karon treatment as the patient will be gastroenteritis, its and vomiting may not the patient was able
paman jud ko kasulay evidenced by asking able to verbalize mode of transmission, correlate the to:
ug inani, wala ko questions. understanding of and its treatment. symptoms with an  demonstrate the
kabalo unsa akong condition/disease acquired intestinal procedure
buhaton”, as process and treatment infection. The client correctly and
verbalized by the as evidenced by may not realize the explain the
patient. demonstrating risk for transmitting reasons for the
procedure correctly the infection to others. action; and
Objective: and explain reasons  expressed correct
 Verbalization of for the action and Assess the client’s The client may not information
the problem expressing correct knowledge on safe understand the regarding the
 Misconception information regarding food preparation and relationship of condition/disease.
the condition/disease. storage. gastroenteritis to the
consumption of
inadequately cooked
food, food
contaminated with
bacteria during
preparation, and foods
that are not
maintained at
appropriate
temperatures.
Educate the client and Knowledge about the
the family about the possible cause of this
causes of and episode of
treatments for gastroenteritis will
gastroenteritis. help the client initiate
to prevent future
 episodes. The client
needs to recognize
that the use of
antibiotics is
controversial in
managing diarrhea.
The client needs to
understand the
importance of fluid
replacement.
Educate the client Good hand washing
about the importance will prevent the
of hand washing after spread of infectious
toileting and perianal agents.
hygiene and before
preparing food for
others.
Educate the client Ground meats are the
about food most common source
preparation and of foodborne
storage methods to pathogens. These
reduce contamination meats should be
by microorganisms. cooked to an internal
temperature of 160°F
and should have no
evidence of pink
color. Raw meats
should be kept
separate from other
ready-to-eat foods. All
utensils and surfaces
that have been in
contact with the raw
meat need to be
washed with hot,
soapy water. Raw
fruits and vegetables
must be washed
before eating if they
will not be cooked.
Only pasteurized
milk, fruit juices, and
ciders should be
consumed. Bacteria
contamination or
growth is more likely
to occur in foods that
are not maintained at
appropriate
temperatures until
eaten.