NURSING CARE PLAN

Diagnosis: AGE Assessment Subjective: Masakit ang tyan ko as verbalized by the patient Nursing diagnosis Acute Pain related to Inflammatory Process AEB Abdominal Pain, Appears weak, Verbalization of pain with a pain scale of 6/10 Facial grimaces, Irritability, sleep disturbances, diaphoresis. Nursing analysis Gastroenteritis is the inflammation of the stomach and intestinal tract that primarily affects the small bowel. One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the body s immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen. Objectives After 3 hrs of nursing interventions the pt. will report pain is relieved from a pain scale of 6/10 to 2/10. Nursing Intervention 1. Established rapport Rationale Evaluation
GOAL PARTIALLY MET:

Objectives: Abdominal Pain Appears weak Verbalization of pain with a pain scale of 6/10. Facial grimaces Irritability sleep disturbances diaphoresis v/s as follows: T: 36.3 RR: 27 PR: 126

1. To gain the trust and cooperation of the patient 2.Monitored and record vital 2. To provide baseline data and signs. note deviations from normal. 3. Reviewed factor that 3. Helpful in establishing aggravate or alleviate pain diagnosis and treatment needs 4. Instructed the SO to 4. To lessen/alleviate pain caused massage the area where pain is By various factors (administer elicited if not contraindicated meds via IV push) 5. Encouraged pain reduction techniques 6. Provided adequate rest 7. Provided diversional activities like socialization 8. Administered analgesics to maintain acceptable level of pain if not contraindicated 9. Instructed client to perform deep breathing exercises (DBE) 5. To reduce pain and promote relief/comfort 6. To promote healing 7. For client s comfort and relief from pain 8. To decrease pain.

After 3 hrs of nursing interventions the pt. reported pain relieved from a pain scale of 6/10 to 2/10.

9. Deep breathing exercises may reduce pain sensation/ used in pain management 10.Monitored effectiveness of 10.To promote timely pain intervention revision of plan of medications care

NURSING CARE PLAN

Diagnosis: AGE Assessment Nursing diagnosis Subjective: Deficient fluid volume RT excessive losses through normal routes AEB frequent passage of loose watery stool Nursing analysis Acute gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The universal manifestation of gastroenteritis is diarrhea which occurs in varying intensity, depending on the organism involved and the health status of the client. Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. Objectives After 4 hours of nursing interventions, the patient or parents will report understanding of causative factors for fluid volume deficit Nursing Intervention 1. Established rapport 2. Monitored and record VS 3.Assessed patient s condition Rationale 1. To gain patients trust 2. To obtain base line data 3.To be aware of the patient s condition and feeling Evaluation
GOAL PARTIALLY MET:

Objective: passage of loose watery stool vomiting abdominal cramping dehydration fatigue weakness weight loss decreased turgor decreased output dry mucous membrane v/s as follows: T: 36.3 RR: 27 PR: 126

After 4 hours of nursing interventions, her the patient as well as 4. Monitored Input & Output 4. to ensure accurate picture of her parents reported understanding of balance fluid status 5.Maintained adequate 5. To prevent dehydration & causative factors for fluid volume hydration, increased fluid maintain deficit intake. hydration status. 6. Provided frequent oral care 6. To prevent from dryness 7.Administered Intravenous 7. To deliver fluids as prescribed fluids accurately and at desired rates. 8. Determined effects of age. 8. Very young and extremely elderly individuals are quickly affected by fluid volume deficit 9. Restricted solid food intake, 9. To allow for bowel rest and to as indicated reduced intestinal workload. 10. Discussed individual risk 10. To prevent or limit factors/ potential problems occurrence of fluid deficit.. and specific intervention

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