Patient M.E.

A was well 2 days prior to admission when he started to develop

diarrhea. It started at 2 am and it was a sudden onset and occurred about 4-5 times a day. The
diarrhea was watery in nature, yellowish to brown in color with no blood stained. Since then, he
had loss appetite and only ate a little amount of foods and drinks. There was no recent history of
taking outside food and travelling.
On Saturday morning which was 2 days after diarrhea occurred, his mother brought him to the
Panpacific Medical center and the doctor prescribed him Oral Rehydration Salt (ORS).
However, the problem was not resolved. His fever and vomiting started a few hours after he
was brought to the Hospital. His mother measured the temperature at home and it was 39.2˚C
(high grade fever) with no rigor. His mother said that there was no rash or joint pain and no
episode of fit since he had the fever. No cough or runny nose. The vomiting started on the same
time with fever. It occurred once and is non-projectile. His mother described the amount of
vomitus was about half of cup, contained fluid but no blood or bilious with slight offensive smell.
There was no history of changing formula milk. His mother said that M.E.A appeared lethargic
and less active than usual during that period. She brought him back to Panpacific Medical
Center at night on the same day. The doctor gave M.E.A. per rectally and antiemetic drugs to

reduce his fever and vomiting. He was diagnosed with acute gastroenteritis with mild
Dehydration.

NURSING CARE PLAN

PATIENT’S INITIALS: Patient M.E.A

Assessment Diagnosis Case Planning Intervention Rationale Evaluation

Background

Subjective: Activity Patient M.E.A Goal: Patient -Monitor vital -To assess and After 8 hours of
C/O intolerance is was admitted to M.E.A will signs record vital nursing
>Mother related to the Panpacific participate signs deviated interventions,
states,“M.E.A generalized Medical willingly in from normal the goal was
appeared weakness as Center desired partially met as
lethargic evidenced by with diarrhea activities. -Monitor input -Ensure that the evidenced by
and less active limited physical and fever as the and output patient has client
than usual activity. chief complaint Objectives: After proper intake of demonstrating a
during that and a diagnosis 8 hours the fluid and other decrease in
period.” of acute patient and nutrients physiological
>Diarrhea and gastroenteritis. patient’s signs of
fever guardian will -Determine the -To provide a intolerance
report client’s current baseline for (e.g.,.pulse,respi
measurable activity level and comparison and rations, and
Objectives: increase in physical activity an opportunity blood pressure
>Temperature activity with observation to track changes remain within
(T=39.2˚C) tolerance. client’s normal
-Encourage -For patient range).
>Characteristic After 16 hours complete bed recuperation
and Findings of patient will rest and recovery The evaluation
Stool demonstrate in will be updated
(Unusual physiological -Provide health -To enhance once data is
Appearance=wa signs of teaching on the patient ability to complete.
tery) intolerance client regarding participate in
(Unusual Color= (e.g.,.pulse,respi the organization activity
yellow to brown) rations, and and time
blood pressure management
remain within technique to
client’s normal prevent while on
range) activity

-Give client -to sustain

and/or clients motivation
guardians