Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient: BASISTA , CHEYENNE RHYZ R. Age: 4 Gender: FEMALE

Chief Complain : ACUTE GASTRO ENTERITIS w/ MOD. DEHYDRATION. Date Admitted: June 29 , 2023 / 10:19 PM

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES/ PLANNING NURSING INTERVENTION EVALUATION

Subjective Data: Deficient fluid volume After 6 hours of nursing Obtain history and The client understands the
“Sige neya uro ngan related to loose watery intervention, the patient will: precipitating factors related causative factor of
suka , nahulop na ak kay stool and vomiting as to occurrenceof diarrhea. diarrhea.
nag pa-pale na sya , mao evidenced by poor skin a)be able tounderstand
adto na nagpa hospital na turgor and pale oral thecausative factorof Provide for changes.in The client
kami” , as verbalized by mucous membrane. diarrhea dietary intake. demonstrates.appropriate
the mother . behavior to assist with
b)have adequatefluid Implement BRATdiet, resolution of causative
Objective Data: balance consisting of.Bread, Rice, factors.
>Vomits 3-4 times Apples, and Toast.
>Pass stool 4 times Long-term: The client displays
(watery texture) After 1 week of Encourage oral intakeof adequate fluid balance as
>Poor skin turgor nursingintervention, the fluids containing evidenced by moist oral
> Dry lips patientwill: electrolytes(Gatorade, mucous membrane, good
>Vital Sign taken as coconutwater, etc.) skin turgor, and normal
follows: a)re-establish andmaintain vital signs.
T: 36.2°C normalpattern of Increase oral fluid intake
P: 109 bpm bowelfunctioning and return to normal diet, The client regains strength
R: 22 cpm as tolerated. from proper hydration.
BP: 90/60 mmHg b)free from fluidvolume
deficit Administer antidiarrheal The client is able to pass
medications, as indicated. formed semi-solid stool.
c)re-establishnormal intake
offluids

d)regain strengthfrom
properhydration

e)pass formedsemi-solid
stool
 NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES/ PLANNING NURSING INTERVENTION EVALUATION

Administer antibiotics After 3 days of nursing
Subjective Data: Infection within urinary The patients will: Report specific to the invading intervention, goal was
“Kay san pagkadi namon tract as evidenced by increased comfort. organism as ordered. partially met as
sa hospital pirme na ine presence of pus cells. evidenced by reduced
siya naka diaper, kay di The Significant Others will If the patient experiences pus cells in the urine.
man ine sa kanya Identify risk factors that perineal discomfort, advice
pagkaon kay ginlilinitahan exacerbate the disease SO to sitz baths to the Significant Others
man namon”, as process or condition and perineum because this may verbalizes understanding
verbalized by the mother. modify the lifestyle of the increase comfort. If sitz of the importance of
patient accordingly baths don’t relieve perineal perineal care to the
Objective Data: discomfort, apply warm patient.
>Pus cells: 50-100 Remain free from signs or compresses sparingly to the
> Dark Yellow Urine symptoms of infection perineum, but be careful not
>Vital Sign taken as to burn the patient.
follows: Patient and family will
T: 36.2°C demonstrate understanding Apply topical antiseptics on
P: 109 bpm importance of perineal care the urethral meatus as
R: 22 cpm every after change of necessary.
BP: 90/60 mmHg diaper .
Collect urine specimens for
culture and sensitivity testing
carefully and promptly.
Encourage patients to
increase fluid intake to
promote frequent urination
 NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES/ PLANNING NURSING INTERVENTION EVALUATION

Readiness for Enhanced Discharge Outcome: *Assess clients GOAL ACHIEVED!!!
Subjective Data: Knowledge: Sanitation After 4days of Nursing perceptions of the current
Intervention the client will be health problems After 4days of Nursing
“Nano man stun an pwede able to use information to Intervention the client
ko himoun para maiwasan develop individual plan to *Determine had be enable to use
na an pag kayaon pus meet health care motivation/expectations for information to develop
cells sa kanya ihi” , as needs/goals. learning individual plan to meet
verbalized by the mother. healthcare needs/goals
Short Term: *Ascertain preferred
After 4hrs of Nursing methods of learning After 4hrs of Nursing
Objective Data: Intervention the client will be Intervention the client
The client manifested: able to verbalize *Provide health education had be enable to
 Cooperative understanding of information about sanitation focusing in verbalize understanding
 Follows instructions gained. the perineal care of the of information gained.
 Active , asking patient.
about the normal
condition of her *Provide information about
daughter additional learning
resources. Such as: books
magazines and TV
programs.