Holy Angel University

NCM 107: Maternal and Child Nursing

S.Y. 2022-2023

Nursing Care Plan

Student Nurse’s Name: Heiley B. Manibog Section & Group: NU-202 Date: February 27, 2023
Client’s Diagnosis: Acute Gastroenteritis with Dehydration
Nursing Diagnosis: Deficient Fluid Volume rt diarrhea and vomiting

Assessment Nursing Diagnosis Plans Interventions Rationale Expected Outcome

S> Short term: ● A decrease in ● The patient will be

The client's S/O Deficient Fluid Volume
reported a watery stool
and persistent vomiting
O>
- Sunken eyeballs
- Poor skin turgor
- (+) Diarrhea
- The client appeared
restless.
After an hour of nursing ● Monitor and circulating blood able to restore fluid
rt diarrhea and interventions, the client document vital signs, volume can cause balance
vomiting and S/O will be able to especially BP and hypotension and
verbalize awareness of HR. tachycardia. ● The patient will be
causative factors and Alteration in HR is a from diarrhea and
behaviors essential to compensatory vomiting
correct fluid deficit mechanism to
maintain cardiac ● The patient
output. Usually, the demonstrate
Medium term: pulse is weak and behaviors or lifestyle
After 24-hour of nursing irregular if electrolyte changes to prevent
interventions, the client imbalance also development of fluid
and S/O will be able to occurs. Hypotension volume deficit.
explains measures that is evident in
can be taken to treat and hypovolemia
prevent fluid volume loss
● Monitor I & O ● To assess their
Long term: hydration status and
After 3 days of nursing determine the need
interventions, the client for additional fluids
will be able to meet the
fluid volume ● Oral fluid
requirements ● Urge to patient to replacement is
drink the prescribed indicated for mild
amount of fluid
 Holy Angel University
NCM 107: Maternal and Child Nursing
S.Y. 2022-2023
Nursing Care Plan
● Emphasize the
importance of oral ● A fluid deficit can
hygiene
● Administer parenteral
fluids as prescribed ●
● Provide perineal care
● To prevent skin
fluid deficit and is a
cost-effective method
for replacement
treatment
cause a dry, sticky
mouth. Attention to
mouth care promotes
interest in drinking
and reduces the
discomfort of dry
mucous membranes
Fluids are necessary
to maintain hydration
status. Determination
of the type and
amount of fluid to be
replaced and infusion
rates will vary
depending on clinical
status.
breakdown due to
diarrhea and
promote comfort.
Use gentle cleansing
and application of
 Holy Angel University
NCM 107: Maternal and Child Nursing
S.Y. 2022-2023

Nursing Care Plan

protective barrier
creams.
● Educate the patient
about the possible ● Enough knowledge
causes and effects of aids the patient in
fluid loss or taking part in their
decreased fluid plan of care
intake

● Emphasize the
relevance of ● Increasing the
maintaining proper patient’s knowledge
nutrition and level will assist in
preventing and
hydration
managing the
problem