Ncp - Age

NURSING CARE PLAN Assessment

Nursing Diagnosis

“Nagtatae at Fluid Volume Nagsusuka” as Deficit r/t active verbalized by the volume loss (active patient fluid loss(prolonged loose, unformed Weak in stool and Appearance vomiting), as - (+) Vomiting evidenced by: - Rashes noted at the back Vital Signs: BP: 100/80 PR: 87 bpm RR: 22 cpm Temp.: 37°C

Background Knowledge Situational Immediate Cause: Active fluid loss (prolonged loose, unformed stool and vomiting), as evidenced by:

Nursing Goal & Objectives

Nursing Intervention

Rationale

At the end of 8 hour shift the patient will be able to maintain fluid volume at a functional level as evidenced by stable vital signs (PR), Intermediate moist mucus Cause: Bacterial/ membranes, good viral process skin turgor and prompt capillary Primary Cause: refill Contaminated food and water. Objectives: After nurse – Health patient interaction, Implications: the patient will be able to: Complications of diarrhea of the 1. Manifest stable Independent: diarrhea include the vital signs Monitor vital Tachycardia is potential for signs present along with a cardiac varying degree of dysrhythmias fluid deficit. Fever because of increases significant fluid metabolism and and electrolyte loss exacerbates fluid loss.

Evaluation Goals met by the end of the shift the patient maintain fluid volume at a functional level as evidenced by stable vital signs (PR), moist mucus membranes, good skin turgor and prompt capillary refill.

Effectiveness: The patient was able to manifest stable vital signs.

(especially loss of potassium) Urinary output of less than 30 ml per hour for 2 to 3 consecutive hours muscle weakness paresthesia, hypotension, anorexia, drowsiness with a low potassium level Decrease potassium levels cause cardiac dsyrhythmias that can lead to death.

2. Maintain accurate a. Monitor intake Fluid replacement intake and output. and output needs are based on correction of current deficits and ongoing losses.

Effectiveness: The patient was able to maintain accurate intake and output.

3. Receive appropriate replacement

Effectiveness: The patient was able to receive appropriate fluid replacement.

a. Provide oral fluid rehydration therapy frequently in small amounts.

b. Replace electrolytes ordered

To replace the fluid losses and prevent further complication like severe dehydration.

To prevent as metabolic imbalance acidosis

and (medical – surgical nursing, Brunner & Suddarth’s, 10th edition, Vol.1, p. 4. Manifest moist Provide frequent To prevent injury Effectiveness: 1032) mucus membranes oral care from dryness The patient was able to manifest Excessive fluid loss moist mucus can lead to membranes hypovolemic shock (medical – surgical 5. Manifest good Encourage nursing, Brunner & skin turgor relatives of the Suddarth’s, 10th patient to provide edition, Vol. 2, p. bath less 2131 frequently using mild cleanser/soap and provide

To maintain skin integrity and prevent excessive dryness

Effectiveness: The patient was able to manifest good skin turgor

optimal skin care with suitable emollients 6. Remain comfortable

7. Receive appropriate pharmacologic treatment

Turn frequently, massage skin, and protect bony prominences

Tissues are susceptible to breakdown because of vasoconstriction and increased cellular fragility

Effectiveness: The patient was able to remain comfortable

Dependent: a. Establish 24 – Prevents peaks/ hour fluid valleys in fluid level replacement needs and routes

Effectiveness: The patient was able to receive appropriate pharmacologic treatment

b. Administer IV To replace fluids as indicated losses

fluid Appropriateness: The intervention were appropriate to the patients condition Acceptability: The interventions were accepted by the patient and her relatives

Adequacy: The manpower, materials and money were adequate to meet the goal and objectives.

NAME: HILARIO, LANI AGE: 17 years old DIAGNOSIS: ACUTE GASTRO ENTERITIS BALAMBAN, KRISHIEL E. BSN III, BLOCK 2 ARELLANO UNIVERSITY – PASAY

MR. ARNEL LIM, M.D. (CLINICAL INSTRUCTOR)