NURSING CARE PLAN FOR ELECTROLYTE IMBALANCE

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Electrolyte After 4 hours of Independent: Goal met

"Nung nagsimula imbalance nursing Ensuring a restful
siyang nagtatae Ensured a comfortable environment is crucial for After 4 hours of nursing
related to intervention the
dahil sa formula environment and adequate supporting the body's interventions, the SO
diarrhea as SO will be able
milk, bigla na lang rest periods. recovery by conserving was able to determine
manifested by to determine the
siyang nawalan ng energy and enhancing the factors that causes
watery stool factors that
gana." as verbalized overall well-being. electrolyte imbalance
affect electrolyte
by the S.O. of the Monitored fluid intake and and the patient was
imbalance and
patient. output. Provides the status of fluid able to improve
the patient will
balance. complications resulting
Objective Data: manifest signs of
from electrolyte
 Uncontrolled improved
bowel Monitored IV rate and imbalance as
condition (e.g., .
movement patency To have the prescribed manifested by a heart
normalized heart
 Diarrhea intake of the patient and to rate of 143 bpm.
rate 100 to 160
avoid dehydration.
 PR/HR: 210 BPM bpm)
Encouraged S.O. to This will help the patient
exclusively breastfeed the regain their appetite.
patient

Education enables the

Educated significant other patient and their family to
regarding potential causes gain a clearer
of dehydration. comprehension of the
diagnosis and learn
preventive measures to
avoid dehydration in the
 future.

Dependent: Alleviates diarrheal

episodes
Administered prescribed
Solzinc syrup medication

NURSING CARE PLAN FOR RISK FOR FLUID VOLUME DEFICIT

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Risk for fluid After 8 hours of Independent: Goal met
volume deficit nursing Ensuring a restful
"First time kong Provided a comfortable environment is crucial for After 8 hours of nursing
related to intervention the
magpainom sa environment and adequate supporting the body's interventions, the
diarrhea and patient will be
kanya ng formula rest periods. recovery by conserving patient was able to
increased able to maintain
milk pagkatapos energy and enhancing maintain adequate fluid
gastrointestinal adequate fluid
bigla na lang overall well-being. volume as evidenced
fluid loss as volume as
siyang nagtatae, Monitored fluid intake and by good skin turgor.
manifested by evidenced by
anim na beses output. Provides the status of fluid
akong nagpapalit sunken good skin turgor.
balance.
ng diapers niya." as fontanel and
verbalized by the decreased skin
turgor Observed for excessively
S.O. of the patient.
dry skin and mucous Indicates excessive fluid
membranes, decreased loss.
Objective Data:
 Bloody stool skin turgor, slowed capillary
 Restlessness refill.
  Sunken fontanel Education enables the
patient and their family to
 PR/HR: 210 bpm Educated significant other
gain a clearer
on possible causes of
 Decreased skin comprehension of the
dehydration.
turgor diagnosis and learn
preventive measures to
avoid dehydration in the
future.

Dependent: Metronidazole aids in

alleviating
Administered prescribed inflammation and irritation
Metronidazole medication. within the GI tract

NURSING CARE PLAN FOR ACUTE PAIN

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Acute pain After 8 hours of Independent: Goal met

related to nursing
"Nakailang tusok Ensured a comfortable Ensuring a restful After 8 hours of nursing
trauma as intervention the
din sila sa kanya, environment and adequate environment is crucial for interventions, the
evidenced by patient will be to
minsan kasi rest periods. supporting the body's patient was able to be
the multiple relax and free
nagkakaroon ng recovery by conserving relaxed and free from
punctured from pain.
problema dyan sa energy and enhancing pain.
sites.
dextrose niya." as overall well-being.
verbalized by the
S.O. of the patient.
Monitored V.S every 2
Objective Data: hours Consistently observe
 Crying essential signs such as
 Trauma temperature, heart rate,
(punctured site) and respiratory rate to
detect any indications of
deterioration or
Located where the complications.
puncture sites are. Influences the amount of
pain experienced.

Monitored skin color and

temperature. Altered in acute pain.

Encouraged adequate rest Prevent fatigue that can

periods. impair ability to cope with
pain.

NURSING CARE PLAN FOR IMPAIRED KIN INTEGRITY

 IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Impaired skin After 8 hours of Independent: Goal met

integrity nursing
"Medyo nagrered na Assess the patient’s skin To provide comparative After 8 hours of
related intervention the
rin yang pwitan niya (perineal area) baseline and opportunity nursing intervention the
infection and SO will be able
kasi lagi kaming for timely intervention when SO is able to show the
discomfort as to show the
nagpapalit ng diapers evidenced by problems are noted. steps of proper
steps of proper
niya." as verbalized by changing of diapers
redness on the changing of
the Excess moisture traps and cleaning the
perineal area. diapers and Maintain clean and dry
S.O. of the patient. microorganisms, thus, perineal area, the
cleaning of the skin. causing infection and patient shows
Objective Data: perineal area,
discomfort decreased redness in
 Redness on and the patient
the perineal area
the perineal will manifest
area decreased
Monitor patient’s hydration. Adequate fluids improve
 Diarrhea redness in the
oxygen and nutrition that is
perineal area
crucial for healing bodily
tissues

Educate the SO on the To avoid further

proper ways of cleaning the complication such as
perineal area and changing infections and discomfort
of diapers

Powders minimize skin

Encouraged the S.O. to irritation
use baby powders after
 cleaning.

NURSING CARE PLAN FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Imbalanced After 4 hours of Independent: Goal met

nutrition: Less nursing
"Napapadede ko Assess the patient’s Promotes efficiency that After 4 hours of nursing
than body intervention the
naman po siya pero nutritional value provides a baseline data intervention the SO is
requirements SO will be able
tae lang po siya ng which leads to a better able to dictate the
related to to dictate the
tae." as verbalized by patient care factors in order to attain
diarrhea factors of
the S.O. of the patient. Use feeding assistance good nutrition and its
secondary to nutrition
(using of baby bottle) benefits for further
Objective Data: increased necessary for
Helping patients with development of
metabolic the patient.
 Watery stool eating and ensuring they patient’s health status.
demand
receive adequate nutrition.
 Diarrhea
Rationale
Educated the patient’s SO
on the complications of not
meeting the metabolic
Helps the SO to provide
demand and consequences
the necessary care and
of deteriorated nutrition
adequate knowledge
Dependent: necessary for the
betterment of the patient
Administered
Metronidazole as
prescribed by the physician
Metronidazole aids in
alleviating inflammation
and irritation within the GI
tract