8/4/2019 Acute Gastroentiritis (NCP)

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Cues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

OReceived lying on bed

w/ IVF #2 D5IMB@ thelevel of 400cc regulated

@ 60 mgtts/min hooked@ right arm, infusing

well:

>V/S taken and recorded as

follows; T 36.3 C

P - 130bpmR -30 cpm

Risk for Deficientfluid volume

Within 8 ofrendering holistic

nursing care the

patient will be ableto maintain fluid

volume @ afunctional level as

evidenced by

individuallyadequate urinary

output with normalspecific gravity,

stable vital signs,moist mucous

membranes, &

good skin turgor.

-Vital signs taken &recorded

-Morning care & bedsidecare done.

-Noted possiblediagnosis that maycreate fluid volumedeficit such as waterdeprivation/ fluidrestrictions, decreasedlevel of consciousness,and vomiting.

-Note physical signs

such as concentratedurine, dry mucous

membranes, delayedcapillary refill, & poor

skin turgor.

-Monitored I & O

-Encouraged to

increased oral intake of

fluids.

-Monitored hydrationstatus.

-IVF regulated @prescribed rate.

-for comparison

- to promote comfort

-to determine otherpossible cause ofdehydration aside from

disease condition.

-to determine signs of

hydration or dehydration

-to maintain accurateinput and output.

-to replace fluid in the

body together with

parenteral fluid infusion

-to monitor for hydration

-to replace fluid losses &prevent cardiac overload

At the end of 8rendering holistic

nursing care the

goal was partiallymet because the

patient receivedlife saving

measures due to

near deathscenario.

Source:

Nursing Diagnosis

with

Intervention

Author:

Marilynn E.Doenges/Mary Frances

Moorhouse

8/4/2019 Acute Gastroentiritis (NCP)

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Cues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

S Nisuka siya ganihakay nadisturbo iyang

katulog as verbalized bythe father

OReceived lying on bedw/ IVF #2 D5IMB@ the

level of 400cc regulated@ 60 mgtts/min hooked

@ right arm, infusingwell:

>V/S taken and recorded asfollows;

T 36.3 C

P - 130bpm

R -30 cpm

Nutrition alteredless than body

requirementsrelated to inability

to ingest or digestfood or absorbnutrients due to

physiologic factors2 to illness.

Within 8 of duty

the pt. will be able

to demonstratebehaviors, lifestyle

changes to regainand/ or maintain

appropriate weight.

-Assess ability toingest food intake

-Auscultate bowelsounds

-Asses weight, age,body build, and

strength activity/ restlevel

-Note total dailycalorie intake

-Explain to SO the

importance of propernutrition and foods

good for health

- -Encourage adequatefluid intake

- Regulate I.V. fluid atdesire rate

- Provide soft diet

-Consult and refer to

dietitian/nutritionalsupport team

-To determine if the aeg

can tolerate in taking

food

-To determine ability todigest (peristalsis)

-To conclude if it isnormal at his age

-To know the nutritional

level intake

-To educate SO

-To replace lost of bodyfluids

- For hydration andnutrients administration

- For easy digestion and

absorption of nutrients

-For proper assessment

After 8 renderingholistic nursing care

the aegs SOdemonstrated

behaviors, lifestylechanges to regain

and/ or maintain

appropriate weightof the patient

Source:

Nursing Diagnosis

with

Intervention

Author:Marilynn E.

Doenges/

Mary FrancesMoorhouse

8/4/2019 Acute Gastroentiritis (NCP)

3/3

CUES NSG DX Planning Intervention Rationale Evaluation

Subjective:Magtubig paginagmay iyang taeAs verbalized by the

mother

OReceived lying on

bed w/ IVF #2D5IMB@ the level of400cc regulated @ 60

mgtts/min hooked @right arm, infusingwell:

- defecated waterystools 2 times duringthe whole shift.- Fair skin turgor

>V/S taken andrecorded as follows;

T 36.3 C

P - 130bpm

R -30 cpm

Diarrhea R/tMalabsorption asevidenced by waterystool.

Signs & Symptoms

- skin pallor noted.- weakness asobserved.

-sunken eyes noted- defecated waterystools 2 times duringthe whole shift.

At the end of 8 hoursof rendering holisticnursing care, the

patient will be able to

maintain normal bowelfunction.

Provide meals to beserved & consumed.

Assist in self care

needs.

Give bed side and

morning care.

take & record V/S.

Provide dry linen asnecessary.

Provide prompt diaperchange and gentlecleansing.

Encourage to increaseoral intake of fluids.

Monitor hydrationstatus.

Regulate IVF atprescribed rate.

Provide adequatecomfort and rest.

Auscultate abdomenfor presence, location,

characteristics of bowelsounds.

Give due PO meds as

ordered.

Restrict solid foodintake as indicated.

Review laboratorystudies

For improvement ofnutritional status.

To promote wellness.

To give patient feeling

of comfort.

For baseline record.

To provide clean drybed.

To avoid skin irritation.

To replace fluid loss.

To monitorimprovement oftherapyTo providesupplemental fluid.

To prevent fatigue.

To assess bowelsounds.

To relieve patient of

diarrhea.

To reduce work load ofsmooth muscles.

To assess condition ofclient.

After 12 hours ofrendering holisticnursing care, the goalwas met as evidenced

by some stoolformation during last

defecation of the shift.