Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Subjective: Deficient Fluid Entry of Short Term: Independent: Short Term Goal:
“Madalas kasi ang Volume r/t Profuse Microorganisms on After 2hrs of • Established To gain trust and
pagtatae ng baby ko Bowel Movement the GI tract continuous nursing rapport to the confidence GOAL
kaya para siyang for 3-5 times a day care and proper client and SUCCESSFULLY
nauubusan ng tubig” secondary to Inflammation health teachings the significant others MET
-As stated by the Inflammation of process occurs patient will manifest: • Monitored and To obtain baseline After 2hrs of
mother the stomach and • Decrease risk for recorded v/s data continuous nursing
intestine Digestive and complications of • Provide proper  To avoid other fluid care and proper
Absorptive Fluid volume ventilation and loses through health teachings the
malfunction deficit cool environment excessive sweating. patient manifested:
• Significant others • Decreased risk
Objective: Excessive gas will have the Health Teachings for
• (+) dry mucous formation proper knowledge done to the S.O.: complications of
membrane regarding the • Instructed to Inc. To maintain Fluid volume
• (+) slightly sunken GI distention disease. Oral Fluid intake hydration status, thus, deficit
fontanels • Significant others of the client avoiding dehydration • Significant
• With fair skin turgor Increase Peristaltic will know the • Advised proper To avoid others acquired
• vaguely weak in Movement proper hygiene of the reoccurrence of the proper
appearance intervention of client disease knowledge
• Defecated 3x to a Mild-moderate the problem. • Adequate rest To avoid exhausting regarding the
yellowish watery Diarrhea and sleep should the patient, this may disease.
stool at Long Term: be provided lead more on fluid • Significant
approximately 1- Fluid Imbalance After 2 days of loss. others
3tsp. continuous nursing Collaborative: understand the
• On Breastfeeding Fluid Volume Deficit care and proper • IVF administered To deliver fluids intervention of
with good sucking health teachings the as ordered. accurately at desired the problem.
ability client will maintain Maintained at rates.
• Weight fluid volume at proper regulation Long Term:
-8kgs. (upon functional level as • Medications given An antibiotic Still on further
admission) evidenced by: as prescribed: kills/diminishes the Evaluation.
-6kgs. (upon • Normalized Bowel -Pen G 400,000 microorganisms
assessment) Movement TIV every 6 hrs. causing the disease,
• Moist mucous thus, preventing
membrane and manifestation to
good skin turgor. occur.
Name of Patient: M.G.V Student Nurse: EBEN EZAR H. DELA CRUZ
Age: 9mos. SMU-SN
Diagnosis: AGE with some signs of DHN