A Nursing Care Plan On

Acute Gastroenteritis with Mild Dehydration

In Partial Fulfillment of the Requirements in NCM 203

Submitted to:
Erein Therese Acero, RN, MN
Clinical Instructor

Submitted by:
Aleah D. Jayagan, St. N

May 6, 2022
Name of Patient: D.P.L Age: 1 yr & 11 mos. Ward: Holy Child Room & Bed #: 207-2 Chief Complaint: Fever Physician: Dr. Chua
Diagnosis: Acute Gastroenteritis with mild dehydration

Date/Time Care Need Nursing Diagnosis Patient Nursing Interventions Implementatio Evaluation
Outcome n
March 3, 2020 Subjective
at 7 am cues: N Hyperthermia related to mild The patient will  Administer The patient’s body
“Murag mubalik dehydration as evidenced by maintain the prescribed temperature is now
napud iyang U irritability, flushed skin, tachycardia, normal body medications to 1 normal so is his
kalintura ma’am. skin warm to touch and lethargy. temperature, and the patient. vital signs. Patient
Init napud iyang T normal vital signs R: Administering the shows no signs of
lawas.’ As Rationale: after prescribed medications weakness.
verbalized by the R Hyperthermia is defined as an administration of will alleviate the Therefore goal is
mother. abnormally high body temperature medications. condition of the patient completely met.
I caused by a failure of the body's and regulates the body
Objective cues: heat-regulating mechanisms to deal temperature. Subjective cues:
T with heat from the environment.
VS taken: Hyperthermia is distinguished from  Performing of “Wala na sya nag
Temp: 38.8 I fever by an uncontrolled rise in body tepid sponge 5 luya nurse, wala
OC temperature that exceeds the body's bath to patient. nasad iyang
RR: 45 cpm O ability to lose heat. The R: Tepid sponge bath kalintura. Pag
CR: 140 bpm hypothalamic thermoregulatory releases heat resulting hikap nako sa
N center's configuration remains to lowering of body iyaha ganina dili na
Skin flushed & unchanged. Dehydration also temperature. init.” As verbalized
warm to touch A contributes to the delay of the by the mother
recovery of the patient (fluid loss).  Proper
Irritability noted L ventilation in the Objective cues:
With proper hydration, medications patient’s room
Look weak - and nursing interventions, the and controlling 3 VS Taken:
patient will be able to recover. the room Temp: 37.1 ° C
With RBS result M temperature. RR: 44 cpm
R: Room temperature CR: 87 bpm
of 16.4 x 109/L
E Reference: and proper ventilation
(N: 5-10 x 109/L Vera, M. (2022). Hyperthermia – greatly affects the
 With T Nursing Diagnosis & Care Plan. patient’s recovery.
Paracetamol 100 Nurseslabs.
mg/ml 1.8ml A https://nurseslabs.com/hyperthermia  Have the
PRN for fever / patient wear
B thin clothing
With IVF of Hyperthermia: too hot for your instead of thick 4 Aleah D. Jayagan,
D5IMB 500 cc @ O health. (2015). National Institutes of clothing in order St. N
40 cc/hr infusing Health (NIH). for the body’s
well at right L https://www.nih.gov/news-events/ne temperature to
metacarpal vein ws-releases/hyperthermia-too-hot- release.
I your-health
R: Overbundling can
C make it more difficult to
reduce a fever.

 Encouraging
the patient to
increase water 2
intake.

R: Increase in water
intake will reduce the
dehydration of the
patient and will help in
lowering the body
temperature.

References:

Vera, M. (2022). Hyperthermia – Nursing Diagnosis & Care Plan. Nurseslabs. https://nurseslabs.com/hyperthermia/

Motrin. (2014). 5 Tips for How to Deal with a Fever from MOTRIN®. MOTRIN®. https://www.motrin.com/adults/cold-flu/5-tips-for-managing-fevers
Herdman, H. &Kamitsuru, S. (2018). Nanda International Nursing Diagnoses: Definitions and classification 2018-2020 (11th ed.). New York, NY: Thieme Publishers.
Cleveland Clinic. (2018). Hyperthermia: Symptoms, Causes, Treatment and Recovery. Retrieved May 6, 2022, from Cleveland Clinic website:
https://my.clevelandclinic.org/health/diseases/22111-hyperthermia ‌
Hyperthermia: too hot for your health. (2015). National Institutes of Health (NIH). https://www.nih.gov/news-events/news-releases/hyperthermia-too-hot-your-health