NURSING CARE PLAN (GROUP-7)

ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective PES format Dehydration SHORT TERM INDEPENDENT INDEPENDEN SHORT TERM
Data - Unable to occurs when - Assess T
● Weakness tolerate the body - After 8hrs patient’s vital - To predict - After 8hrs of
● Flu-like fluids loses more signs the long-term
of Nursing Nursing
symptoms related to fluid than it patient health
Intervention, - Assess the Intervention,
● Unable to Nausea and takes in, outcomes and
tolerate vomiting as leading to a the patient patient’s oral the patient
fluids due evidence by lack of water will be able to mucosa and skin return Was able to
turgor. emergency
to nausea reports of and other - Exhibit no department - Exhibit no
and weakness essentials. signs of - Encourage the signs of
vomiting and flu-like Diarrhea and dehydration patient to drink - used as a dehydration
in 3-4 days vomiting can oral rehydration way to check
and good skin for and good skin
Objective cause solutions to
Data significant turgor. replace lost dehydration turgor.
● Liquid loss of water - Retain fluids and - To prevent - Retain
stools 2-4 and feeding electrolytes. nausea and feeding
times per electrolytes, without vomiting, give without
day with flu-like experiencing in small, vomiting.
● Ht: 5’3 symptoms frequent sips
vomiting.
● Wt: 166 lbs lasting 3-4 DEPENDENT: only.
● Temp: 38.6 days. The - Give 500mg DEPENDENT:
● PR: 86 bpm condition Paracetamol
● RR: 24 cpm worsens with -to treat mild
every 4 hours as to moderate
● BP: 130/90 fever and per the doctor’s
● Urine diarrhea, pain
LONG TERM LONG TERM
 Specific resulting in - After 5 days order. - to treat
Gravity:1.03 concentrated of Nursing - Give sudden - After 5 days
57 urine, which Intervention, antidiarrheal diarrhea of Nursing
● Serum can cause medication (e.g:
the patient Intervention,
Sodium: 155 bladder Imodium) as per
must be COLLABORAT the patient
meq/L irritation and the doctor’s
● CXR: increase the - Stay IVE: was able to
order.
Negative risk of hydrated. - to help - Stay
urinary tract - Monitor determine a hydrated.
infections. fluid intake COLLABORATIV diagnosis.
- Avoid E:
dehydrating - Refer to the
substances patient's
physician for
and eat
dietary
hydrating modifications
foods needed.