UNIVERSITY OF PANGASINAN

COLLEGE OF NURSING
PHINMA EDUCATION NETWORK

NURSING CARE PLAN

Name: Patient X Age: 14 y/o

 ASSESSMENT NURSING NURSING GOAL & INTERVENTIONS RATIONALES EVALUATION
DIAGNOSIS ANALYSIS OUTCOMES

S >”Nagsusuka ako, Fluid Volume Due to active fluid Goal: The patient 1. Assess patient > This can help to Goal Partially Met:
nahihilo at masakit Deficit R/T active loss through fluid and about the cause of guide The patient exhibited
ulo ko” as verbalized fluid loss AEB dry vomiting, electrolyte loss vomiting. interventions. minimal relief of signs
by the patient. lips, facial electrolyte will be replaced and symptoms and
grimacing, weak imbalances will and will exhibit 2. Side rails up. partial fluid and
O > dry lips in appearance, occur such as relief from signs > To prevent electrolytes
> facial grimacing pain scale of 9/10 hypokalemia and and symptoms accidental fall. replacement at the end
> pain scale 9/10 and verbal reports hyponatremia that through 8 hours of of 8 hours of nursing
> weak in vomiting, results to nursing care. care.
appearance dizziness and weakness, 3. Positioned
> headache. lethargy and patient in semi
nausea. fowlers.

To maintain an
open airway.
4. Check for the
V/S.

5. Assess skin
turgor. > To evaluate if
there are
abnormal vital
signs.

6. Obtain
specimens for
> To note any
analysis of altered
sign of
potassium levels
dehydration
(e.g.,

serum and urine

potassium)
> Urine and
 UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
PHINMA EDUCATION NETWORK

DRUG STUDY
 DRUG NAME DRUG ACTION INDICATION & DRUG-DRUG CONTRAINDICATIO ADVERSE NURSING
DOSAGE INTERACTIONS NS REACTIONS CONSIDERATIONS

Generic Name; > relieves indicated for Additive sedative Myasthenia >xerostomia >Assess for eye pain
Hyoscine cramps, spasms of the control of effects with gravis, >tachycardia >Monitor Output ration
the stomach, abdominal alcohol or other megacolon. >urinary retention >Assess for
Brand Name: intestines and pain (colic) CNS depressants. Parenteral >allergic and skin parkinsonism and EPS
Buscopan bladder. associated Reduced effects Untreated narrow- reaction >Assess for urinary
with with angle glaucoma, hesitancy
Classification: spasmodic acetylcholinestera prostate >Assess for
Antispasmodic colic, flatulent se inhibitors hypertrophy w/ constipationAssess for
colic. (donepezil, urinary retention, tolerance over long
galantamine, mechanical term therapy
rivastigmine, stenosis of GIT,
ADULTS AND tacrine). tachycardia
CHILDEN>6y/o:

1-2 tabs 3-5 times

daily.