Sample Ncp Table With Sample Priorotization And Justification Of Problems

Problem: Diarrhea and Dehydration Explanation of Assessment Problem

Goal and Objectives

Nursing Interventions

Rationales

Evaluation

SAMPLE NCP Subjective data:  “basa yung tae niya, matubig at mabaho na ang laman ay kanin at iba pa niyang nakain kanina”, as verbalized by the mother.  “His eyes appear to have become deeper and his mouth and tongue appears slightly dry”, as verbalized by father.  Frequently requests to drink water

Objective data:  Dry skin and mucus membranes  Sunken fontanelles  Poor skin turgor  10 bowel movements in 8 hour shift  Rice watery yellowish stool with foul odor

Diarrhea resulted from ingestion of food carrying pathogenic microorganism that entered the GI tract. This invasion caused activation of the inflammatory process that altered regular absoption and metabolic processes. Increased peristaltic movement led to diarrhea episodes that led to fluid loss, thus dehydration signs and symptoms.

LTO: After 72 hours of Nursing Interventions, the client will exhibit optimal hydration status as manifested by: - Good skin turgor - Moist skin and mucus membranes - Hematocrit within normal range of 0.40- 0.54 STO: After 8 hours of Nursing interventions, the client will exhibit reduction in fluid loss as manifested by: - Lesser bowel movement from 10 per shift to at least once per day - Elimination of formed stools -

Diagnostic: 1. Monitor vital sign -observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume

2. Review laboratory results – hematocrit, urinalysis and fecalysis

3. Monitor for inelastic skin turgor, thirst, dry tongue and mucous membrane, longitudinal tongue furrows, speech difficulty

Diagnostic: 1. A decreased pulse pressure is an earlier indicator of shock from dehydration than is the systolic blood pressure. Decreased intravascular volume results in hypotension and decreased tissue oxygenation. 2. Increased hematocrit and increased urine specific gravity are signs of increasing blood concentration usually from dehydration. Reviewing fecalysis may identify source of diarrhea and dehydration. 3. These are signs of deficient fluid volume. Since inelastic skin turgor, thirst and dry tongue

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amounting to 700 mL per bout of diarrheal episode Laboratory Result Blood Test Hematocrit: 0.55 Fecalysis result with positive amoeba idenitification

Nursing Diagnosis: Fluid volume deficit related to excessive fluid and electrolyte loss through normal route.

, dry skin, sunken eyeballs, weakness (upper body) and confusion.

4. Observe and record Intake and output including: bowel movement frequency, amount, characteristics and precipitating factors 5. Monitor daily weight

6. Identify foods and fluids that aggravate or precipitate diarrhea. Therapeutic: Independent 1. Provide fluids

and mucous membrane are manifested by the client upon admission, it is important to check these to see if there is significant improvement in hydration. 4. This is done to see if extent of fluid loss

5. Body weight changes reflect changes in body fluid volume. A 1- pound weight loss reflects a fluid loss of about 500 mL. 6. This is done to avoid them in order to avoid a more severe case of diarrhea. Therapeutic: Independent 1. The oral route is preferred for maintaining

2. Provide prescribed diet BRACT –banana, rice, crackers, toast diet ;

3. Provide positional changes

4. Rest the bowel when client is vomiting or has diarrhea (e.g., restrict food or

fluid balance. Distributing the intake over a 24- hour period accompanied by snacks and preferred beverages increases the likelihood that the patient will comply with the prescribed oral intake. 2. Provides essential nutrients and helps avert liquid and soft stools (low in fiber and caffeine that can increase intestinal motility) 3. Promotes skin integrity (e.g., monitor areas for breakdown, ensure frequent weight shifting) becausedeficien t fluid volume decreases tissue oxygenation, which makes the skin more

fluid intake when appropriate, decrease intake of milk products).

Collaborative 1. Hydrate patient with Oresol as ordered by physician. 2. Administer Metronidazole as ordered by physician.

Educative: 1. Instruct client and family about signs of deficient fluid

vulnerable to breakdown. 4. Prevents further inflammation and irritation of GI tract. The most common cause of deficient fluid volume is gastrointestinal loss of fluid. At times, it is preferable to allow the gastrointestinal system to rest before resuming oral intake. Collaborative 1.Oresol rehydrates patients and replenishes lost electrolytes . 2. Metronidazole Interacts with DNA of Entamoeba histolytica (causative agent of Amoebiasis that caused the diarrhea of the patient) to cause strand breakage and loss of helical structure effects that result

volume that indicate they should contact health care provider. 2. Instruct client and family the correct technique for hand hygiene and to always perform it as much as possible. 3. Instruct client and family about risks of eating food not cooked by them and drinking water at questionable sources.

in the inhibition of nucleic acid synthesis that leads to cell death.

Educative: 1. In order to not make the dehydration more severe, immediate action must be done upon seeing signs of dehydration. 2. This is a safety measure used to avoid microorganisms to enter the body. 3. Since diarrhea caused by water drank at questionable sources and food eaten that are cooked outside the home are most likely to cause diarrhea, it is important for the family to kmow where should they

drink water and food that won’t harm their gastrointestinal tract for preventive measures.

SAMPLE JUSTIFICATION AND PRIOROTIZATION OF PROBLEMS

Identified Problems:

Justification

1. Ineffective airway clearance related to retained secretions –In Maslow’s hierarchy of needs, airway can be considered as a priority need because airway ensures oxygen delivery to the lungs and tissues in general. This is prioritized because according to ABC prioritization tool, airway is the foremost need/priority. Airway sustains delivery of oxygen that is very crucial to life. 2. Fluid volume deficit related to excessive fluid and electrolyte loss through normal route. - This is prioritized as second because according to ABC prioritization tool, breathing is the second need/priority to be met, furthermore, fluid takes precedence over other physiologic needs like food and temperature and clothing. 3. Hopelessness related to inadequate support system –CONTINUE JUSTIFYING