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Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation Subjective: Independent

The patient's mother reported that her child was experiencing diarrhea. Upon assessment, the nurse noted loose watery stools, hyperactive bowel sounds, poor skin turgor, dry lips, decreased sodium levels, and weight loss. The nurse diagnosed the child with risk for fluid volume deficit related to gastroenteritis. The nurse's plan was to monitor for signs of dehydration, encourage increased oral fluid intake, and administer prescribed medications to reduce diarrhea and prevent further fluid loss. After 3 hours, the goal was met as the child demonstrated good skin turgor and no further signs of fluid volume deficit.

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79 views

Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation Subjective: Independent

The patient's mother reported that her child was experiencing diarrhea. Upon assessment, the nurse noted loose watery stools, hyperactive bowel sounds, poor skin turgor, dry lips, decreased sodium levels, and weight loss. The nurse diagnosed the child with risk for fluid volume deficit related to gastroenteritis. The nurse's plan was to monitor for signs of dehydration, encourage increased oral fluid intake, and administer prescribed medications to reduce diarrhea and prevent further fluid loss. After 3 hours, the goal was met as the child demonstrated good skin turgor and no further signs of fluid volume deficit.

Uploaded by

georgia
Copyright
© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSING SCIENTIFIC

ASSESSMENT PLANNING NURSING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS EXPLANATION
Subjective: Risk for Fluid Gastroenteritis, also After 3 hours, Independent: The goal was
“Nagtatae ang Volume known as infectious the patient will 1. Assessed the patient’s skin 1. A loss of interstitial met.
anak ko.” as Deficit related diarrhea, is show no signs of turgor and mucous fluid causes the loss of
verbalized by the to diarrhea inflammation of the fluid volume membranes for signs of skin turgor. The patient
mother gastrointestinal tract deficit as dehydration. demonstrated
that involves the evidenced by good skin turgor.
Objective: stomach and small good skin turgor. 2. Assessed the consistency and 2. The inflammation in the
 Loose watery intestine. Symptoms number of bowel large intestine limits the
stools may include diarrhea, movements. colon’s ability to absorb
 Hyperactive vomiting and water, leading to fluid
bowel sounds abdominal pain. Fever, volume deficit.
upon lack of energy and
auscultation dehydration may also 3. To evaluate the
 Poor skin occur. This typically 3. Assessed the patient’s vital progress of volume
turgor lasts less than two signs. deficit and any
 Dry lips weeks and it is not complications.
 Weight = related to influenza
 Na level= though it has been 4. The client with
127.9 mmol/L called the stomach flu. 4. Monitored the patient’s gastroenteritis may
(decreased) weight daily experience weight loss
from fluid loss with
Reference: diarrhea.
Porth, C.M.
(2005).Essential of 5. To prevent dehydration.
Pathophysiology: 5. Encouraged the mother to
Concepts of altered increase oral fluid intake of
his child as instructed by the
health states. 2nd
physician 6. This measure conserves
edition. pp. 89-90, 656
patient’s energy
6. Emphasized to the mother
the importance of adequate
rest periods for his child.
1. To provide
Dependent: pharmacological
1. Administered Pedialyte and management (reduces
Probiotics twice a day as diarrhea and prevent
prescribed by the physician. dehydration)

Interdependent: 1. To determine the


1. Monitored laboratory studies effectiveness of
such as fecalysis and treatment/management
electrolytes. rendered to the patient

Reference:
Doenges M.E., Moorhouse
M.F., and Murr A.C.
(2006). Nurse’s Pocket
Guide: Diagnoses,
prioritized interventions
and rationales, F.A. Davis
Company, 10th edition

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