Nursing Care Plan for Latorre, Marvin Leigh Soriano.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid volume  It occurs when Short term goal: Independent: 1. these measurements
“4 na araw na deficit as the body loses provide useful data for After 8 hours of
siyang evidenced by both water After 8 hours of 1.weigh clients daily comparison. intervention Pt. has
nagsusuka” as vomitting and electrolytes f intervention Pt. will input and output only vomit one time
verbalized by the rom the ECF in maintain fluid 2.  Fever increases at 2:15 pm. Partially
mother of the Pt. similar volume at the 2. Monitor VS and metabolism and met.
“6 na araw narin proportions. functional level by observe for temp exacerbates fluid loss
siyang nagtatae” Common sources not vomiting and elevation. After 2 days of
having watery stools 3. A decreased urinary intervention patient
as verbalized by of fluid loss are
the mother of the the 3. Monitor urine output output may indicate demonstrated good
hypovolemia requiring
pt. gastrointestinal Long term goal: skin turgor, good
more aggressive fluid
tract, polyuria, 4. Provide safety capillary refill,
replacement.
Objective: and increased After 2 days of precautions, as indicated, moist mucous
4. requiring protective
Pt. is lethargic, perspiration. intervention Pt. will such as the use of side membrane and
measures to prevent
has dry skin, oral demonstrate good rails adequate urinary
client injury
mucosa and skin turgor, good refill. Goal met.
capillary refill, moist 5. encourage high fluid .
sunken eyes. 5. Relieves thirst and
mucous membranes intake when NPO is no
longer instructed discomfort of dry
and adequate urinary mucous membranes and
output with normal augments parenteral
specific gravity. 6 Bathe every other day
replacement
using mild soap. Apply
6. Daily bathing may
lotion, as indicated.
increase dryness
Dependent:
7. Rehydration after
becoming dehydrated
7.Administer IV fluids
as per physicians order.
8. metoclopramide is
8.Administer
used to stop vomiting
Metoclopramide 5mg
and Omeprazole is
IV and Omeprazole
used to decrease the
20mg IV as per
amount of acid in the
 stomach.
physicians order. 9. provide reliable
information about the
9. Monitor Laboratory patient.
Results