NURSING CARE PLAN DIAGNOSIS 1.

Fluid volume deficit related to excessive looses through normal routes as evidenced by frequent passage of loose watery stool, dry skin and poor skin turgor.

PRIORITIZATION

RATIONALE Next to ABCs of life is the Maslows Hierarchy of needs. Fluids are involved in the first level of Maslows Hierarchy of needs which is in the bracket of physiologic needs. Fluid is essential to health because it aids in thermoregulation, hydration and vehicle for waste excretion.

High

2. Diarrhea related to irritation of GI tract as manifested by passage of watery stool and hyperactive bowel sound.

Medium

Diarrhea belongs to the first level of Maslows Hierarchy of needs which is in the bracket of physiologic needs. Elimination of waste products of digestion from the body is essential to health.

3. Knowledge deficit related to information misinterpretation as evidenced by verbal report of the patients SO.

Low

Knowledge is the last in the prioritization because knowledge about some diseases will help each one of us to prevent it from happening.

ASSESSMENT Subjective Cue: Nagtatae sya, as verbalized by the mother. Objective Cues: - Watery stool for 1day - Dry skin - Poor skin turgor - Pale and weak in appearance Vital signs: y Temp- 36.2C y PR- 102 bpm y RR- 24 cpm

DIAGNOSIS Fluid volume deficit related to excessive looses through normal routes as evidenced by frequent passage of loose watery stool, dry skin and poor skin turgor.

PLANNING Short term: After 4 hours of nursing interventions, the patient will report understanding of causative factors for fluid volume deficit Long Term: After 1-2hrs of nursing interventions, the patient will maintain fluid volume at functional level as evidenced by stable vital signs and good skin turgor.

INTERVENTION Independent:  Weighed client and compares with recent weight history.  Encouraged to increase oral fluid intake.  Encouraged to eat nutritious foods.  Observed for excessively dr y skin and mucous membranes, decreased skin turgor, slowed capillary refill.  Provide safety measures. Dependent:  Administer medications as ordered.  Administer IV fluids as ordered.

RATIONALE  for baseline data

EVALUATION Short term: Goal met. After 4 hours of nursing interventions, the patient was reported understanding of causative factors for fluid volume deficit Long Term: Goal met. After 1-2hours of nursing interventions, the patient was maintained fluid volume at functional level as evidenced by stable vital signs and good skin turgor.

 to replaced fluid loss

 Indicates excessive fluid loss/resultant dehydration

 to promote safety

 to correct/replace

fluid loss.

ASSESSMENT Subjective Cue: Tae sya ng tae ng lusaw, parang tubig, as verbalized by the mother. Objective Cues: - 6-7 watery stool for 1day - Soft stool - Hyperactive bowel sounds upon auscultation. Vital signs: y Temp- 36.2C y PR- 102 bpm y RR- 24 cpm

DIAGNOSIS Diarrhea related to irritation of GI tract as manifested by passage of watery stool and hyperactive bowel sound.

PLANNING Short term: After 30 minutes of nursing interventions, the patient will be able demonstrate appropriate behavior to assist with resolution of causative factors. Long Term: After 8hrs of nursing interventions, the patient will be able to reestablish and maintain normal pattern of bowel functioning.

INTERVENTION Independent:  Encouraged to increase oral fluid intake containing electrolytes.  Encouraged to eat nutritious foods.  Emphasized the importance of hand hygiene before and after eating. Dependent:  Administer antidiarrheal medication as ordered.  Administer IV fluids as ordered.

RATIONALE  to maintain fluid and electrolyte balance   to avoid spread of micoorganism

EVALUATION Short term: Goal met. After 30 minutes of nursing interventions, the patient was able to demonstrate appropriate behavior to assist with resolution of causative factors. Long Term: Goal met. After 8hrs of nursing interventions, the patient was able to re-establish and maintain normal pattern of bowel functioning.

 to treat the disease

 to correct/replace

fluid loss.

ASSESSMENT Subjective Cue: Hindi ko nga alam kung bakit sya nagtae, as verbalized by the mother, Objective Cues: -

DIAGNOSIS Knowledge deficit related to information misinterpretation as evidenced by verbal report of the patients SO.

PLANNING Short term: After 30mins of nursing interventions, patients mother will be able to verbalize understanding regarding disease process and treatment. Long-term: After 8 hours of nursing interventions, the patients mother will be able to initiate necessary lifestyle changes and participate in treatment regimen towards the wellness of her daughter.

INTERVENTION  Provided information relevant to situation.  Provided positive reinforcements and avoided to use of negative reinforcement.  Discussed clients perception of need.

RATIONALE  To provide knowledge about the disease  can encourage in continuing the efforts

EVALUATION Short term: After 30mins of nursing interventions, patients mother was able to verbalize understanding regarding disease process and treatment. Long-term: After 8 hours of nursing interventions, the patients mother was able to initiate necessary lifestyle changes and participate in treatment regimen towards the wellness of her daughter.