NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(cite source)
Subjective cues: Risk for loneliness related Short Term: Independent Short Term:
to

At the end of 8 hrs, 1. Monitor intake and - Accurate After 8 hours of nursing
client will be able to: output of patient measure of fluid intervention, the client’s
intake and mucosa is moist, have
Objective Cues: output is an less episodes of
- The mother important diarrhea, and have a
will be able to indicator of a complete understanding
understand patient's fluid of the rationale for
the rationale status. treatment. The client
of the shows a negative stool
treatment culture. The Parent was
- To facilitate able to demonstrate
- have less how to prepare an
fluid
episodes of alternative of ORESOL.
replacement.
diarrhea The significant other
2. Encourage the
- increase fluid and the patient
client to increase
intake verbalizes
fluid intake.
understanding about
- regain optimal - Dehydrated the contributing factor
energy and client may be that is causing diarrhea.
and have a 3. Assist client and weak.
encourage family
 feeling of members to
comfortable provide assistance
Long Term:
if client is unable to
- have negative
eat on his own
stool culture
(normal After 24 hours, the
characteristics client was able to
4. Educate the client - To prevent the
of stool) replenish fluid loss in
and family severity of
the body, and maintain
- collaborate members on the dehydration
good skin turgor
with his importance of and
(pinched skin spring
significant proper hydration malnutrition.
back into place within
other on and nutrition
two seconds), and
understanding
regain all lost fluids and
and making of
maintain optimal weight
an alternative 5. Monitor and
level of 18 kg.
form of document vital
Significant others are
hydration signs especially BP - Decrease in able to understand the
and HR. circulating patient’s condition and
blood volume collaborate to provide a
Long Term: can cause proper diet at home.
hypotension
and
After 24 hrs, the client tachycardia.
will be able to: Usually, the
pulse is weak
and may be
- maintain good irregular if
skin turgor electrolyte
and weight imbalance also
level. occurs.

- replenish fluid
loss in the
body
- Monitoring
consistency of
6. Monitor stool as well as
consistency, the
 frequency, and characteristics
characteristics of and the number
the stool of times the
patient
defecates will
help check the
patient's
progress of his
condition.

- Educating the
patient about
the importance
of taking
ORESOL and its
alternative will
help the family
7. Educate the
lessen the costs
parents on how to
of medication
prepare
and will support
alternatives for
proper
ORESOL.
rehydration of
the patient at
home.

- BRAT diet helps

your digestive
system get back
on track and
speed up
recovery.
 8. Educate the
patient and his
- contains water,
significant others
salts, and sugar
about the BRAT
that are needed
diet/ Soft diet.
to replace lost
body fluids.

- considered in
first line
Dependent (optional)
therapy for
infectious
diarrhea only
1. Give the patient during specific
ORESOL circumstances

- To replenish
2. Administer the lost fluid with
patient with appropriate
antibiotics foods that
prevent
dehydration
and avoid foods
that can irritate
the digestive
system.

Collaborative
- To prevent
1. Coordinate with infection
nutritionist about
proper food
options - Proper
monitoring of
electrolytes
helps regulate
the balance of
fluids in the
body.
Regulating
blood pressure,
muscle
contraction and
making your
2. Give antibiotics as system
prescribed functioning
properly.

3. Assist on
laboratory References:
procedures - Wayne, G.,.
(electrolyte inside (2020,
the body) September 7).
Fluid Volume
Deficit
(Dehydration)
Nursing Care
Plan
https://nursesla
bs.com/deficien
t-fluid-volume/
ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
(cite source)
Subjective cues: Deficient Fluid Volume Short Term: Independent Short Term:
r/t vomiting AEB 10
episodes of vomiting,
● “Ika-10 nani clear then yellow After 8 hours of 1. Monitor vital signs. - To determine After 8 hours of nursing
siya naka tinged. nursing intervention, the level and intervention, the
suka... ”, as the client will be able severity of client’s mucosa is moist,
verbalized by to: dehydration. have stopped vomiting,
the mother and have a complete
- The mother
understanding of the
● “kapuy kaayu will be able to
- To determine rationale for treatment.
iyahang understand the
severity of The Parent was able to
pamainaw”, as rationale of 2. Monitor frequency, vomiting and its demonstrate how to
verbalized by the treatment characteristics and progress prepare an alternative
the mother consistency of
- be relieved of ORESOL. The
from episodes vomiting. significant other and
of vomiting/ - To monitor the patient verbalizes
Objective Cues: understanding about
stop vomiting. disturbance in
3. Assess for presence of the patient’s the contributing factor
- collaborate tachycardia, postural that is causing diarrhea.
health
● Skin turgor with his hypotension, skin
somewhat significant turgor/skin hydration,
diminished other on and condition of Long Term:
understanding mucous membranes.
● 10 episodes of and making of
vomiting (clear an alternative
then yellow - To monitor After 24 hours, the
form of 4. Document actual
tinged) changes of the client was able to
● 5% dehydrated hydration. weight using weighing patient’s replenish fluid loss in
scale weight. the body, and maintain
● Malaise
good skin turgor
Long Term: (pinched skin spring
back into place within
two seconds), and
5. Consider small - Eating small, regain all lost fluids and
After 24 hours of
nutrient-dense meals frequent meals maintain optimal
nursing intervention,
instead of larger can help lessen weight level of 18 kg.
the client will be able
meals. the feeling of Significant others are
to:
fullness and able to understand the
decrease the patient’s condition and
stimulus to collaboration was
- maintain good vomit.
skin turgor and achieved to provide a
weight level. proper diet at home.

- replenish fluid - To help

loss in the decrease stress
body 6. Provide a pleasant and reduces the
environment. Home gastric
ventilation, optimal stimulation and
room temperature, vomiting
adequate light, response.
eliminate unnecessary
noise.
- Elevating head
can aid in
7. Promote proper swallowing and
positioning of the reduce risks for
body. aspiration

- Promotes
reduction of
medication
8. Educate the parents costs.
on how to prepare
 alternatives for
ORESOL (e.g. 6 level
teaspoons of sugar
and 1/2 level
teaspoon of salt
dissolved in 1 litre of
clean water.)

Dependent (Optional)

- Administer ORESOL to - ORS contains

patient as prescribed water, salts, and
sugar that are
needed to
replace lost
body fluids. Ask
what kind of
ORS to use, how
much to give
your child, and
where to get it.

- Dietician can aid

in discussing
Collaborative and planning to
meet the
client’s
1. Coordinate with nutritional goals
dieticians about Soft
diet.
 - Proper
monitoring of
electrolytes
2. Assist on laboratory helps regulate
procedures the balance of
(electrolyte inside the fluids in the
body) body.
Regulating
blood pressure,
muscle
contraction and
making your
system
functioning
properly.

References:

- n.a. (n.d).
Nursing Care
Plan & Diagnosis
for Vomiting |
Risk for Fluid
Volume
Deficient &
Acute Pain.
RegisteredNurse
RN.com.
Retrieved from:
https://www.re
gisterednursern.
com/nursing-
care-plan-
diagnosis-for-
 vomiting-risk-
for-fluid-
volume-
deficient-acute-
pain/

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

(cite source)
Subjective cues: Altered body Short Term: Independent Short Term:
temperature r/t infection
AEB increase in body
● “gagmay ra temperature After 4 hours of nursing 1. Educate client and - To prevent After 4 hours of nursing
syag kaon intervention, the family members on transmission of intervention, the
dayon gisingot patient will be able to: proper bacteria patient's temperature
ug ayo, ang handwashing and decreases to 37 degree
1. maintain a
temperature hygiene Celsius and verbalized
normal body
niya pag check feeling comfortable.
temperature
sa balay kay
101 degrees”, 2. Educate client and
as verbalized family members - Providing health Long Term:
by the mother Long Term:
about the signs and teachings to
symptoms of client and
hyperthermia; family aids in After 2 days of nursing
Objective Cues: After 2 days of nursing identify factors coping with the intervention, the
intervention, the related to the disease patient shows stabilized
patient will have a occurrence and condition and temperature ranging
stabilized normal discuss importance
● Pulse Rate: 110 helps prevent from 36.6 degree
temperature and will of ample fluid
bpm further Celsius to 37.2 degree
verbalize feeling
complications
● Respiratory comfortable. intake Celcius.
Rate: 45 cpm

● Temperature:
3. Encourage
38.2 degrees
generous amounts
Celsius - To prevent
of fluid intake
dehydration;
● Slightly Pale
fluid loss
● Dry and pale contributes to
mucous fever
membrane

● Febrile (warm 4. Eliminate excess

- Exposing skin to
to touch) clothing and covers
room air
● Malaise reduces warmth
and promotes
cooling

- Promotes
5. Administer Tepid cooling and
Sponge Bath comfort

- Temperature of
38 degree
6. Monitor patient celsius and
temperature above may
degree and pattern suggest an
of occurence acute infectious
disease process.

Dependent - Antipyretic
medications
lower body
1. Give antipyretic temperature by
medication as prescribed blocking the
synthesis of
prostaglandins
that act in the
hypothalamus

- Shivering causes
rapid
contraction in
the skeletal
muscles that
leads to
increase in
2. Provide Opioid temperature
analgesics (meperidine) and it also
when excessive shivering increases the
occurs. metabolic rate
in the liver
which worsens
the total body
temp. of the
patient.

- Intravenous
normal saline
solution
replenishes fluid
loss
 - Appropriate
diet is necessary
to meet the
metabolic
demand of the
patient
3. Start intravenous normal
saline solution as
prescribed - Fever increases
metabolic
demands and
consequently
oxygen
Collaborative consumption of
different
organs, notably
1. Provide a high- the brain and
caloric diet as the heart, and
indicated by the worsens pre-
physician. existing disease.

References:

Wayne G., (2017, September

24). Hyperthermia Nursing
2. Ready oxygen Care Plan.
therapy for https://nurseslabs.com/hyper
thermia/
extreme cases.