VI.

Nursing Management NURSING CARE PLAN ASSESSMENT Subjective cues: nagtae man na siya sugod kagahapon, nagluya na dayon siya as verbalized by mother Objective cues: >sunken eyeballs >irritable >lethargic >dry mucous membranes DIAGNOSIS PLANNING Fluid volume deficit Short term: related to active fluid loss At the end of 2 hours: y patient will maintain fluid volume at functional level as evidenced by stable vital signs alertness and moist mucous membranes Long term: y At the end of 6 hours: patient will verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications IMPLEMENTATION Independent: y Establish 24 hour fluid replacement needs and routes to be used y Provide frequent oral care as well as eye care Increase fluid intake Vol/vol replacement with oresol RATIONALE EVALUATION Short term: Patient maintained fluid Prevents peaks and valleys in fluid volume at functional level as evidenced by stable level v/s, alertness and moist mucous membranes To prevent injury from dryness

To rehydrate To replace fluid losses Provides continuous rehydration and replace fluid losses

Long term: Patient understood the cause of dehydration and the purposes of his medications and therapeutic regimen

Dependent: y Administer D5IMB 500ml at 42ugtts/min as ordered

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ASSESSMENT Subjective cues: sugod kagahapon gasakita nana iyahang tiyan dayon galibang na as verbalized by mother

DIAGNOSIS Diarrhea related to infectious processes/parasites

PLANNING Short term: At the end of 2 hours: y patient will demonstrate appropriate behavior to assist with the resolution of causative factors Long term: At the end of 6 hours: y patient will reestablish and maintain normal pattern of bowel functioning

IMPLEMENTATION Independent: y Auscultate abdomen

RATIONALE To know presence, location and characteristics of bowel sounds To avoid food that precipitate diarrhea

EVALUATION Short term: Patient demonstrated appropriate behavior to help rule out the cause of diarrhea

Objective cues: >5 liquid stools per day >yellow colored stool >WBC lab result:17,200

Provide for changes in dietary intake (limit caffeine and high fiber foods) Review causative factors and appropriate interventions Determine recent exposure to a different environment, change in drinking water or food intake Review food preparation emphasizing on adequate cooking time

To prevent reoccurrence

Long term: Patient re-established normal bowel pattern and functioning

May help identify causative environmental factors

To prevent bacterial growth/contaminat ion

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Weigh diaper

To determine output and fluid replacement needs Prevents growth of microorganisms

Encourage proper hand washing and hygiene

Dependent: Administer Mebendazole 100mg 15ml/5ml, 5ml OD PO X 3 drops Administer enema as ordered

For the treatment of parasitic infections

To clean the bowel

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ASSESSMENT Subjective:

DIAGNOSIS Hyperthermia related to active fluid loss

PLANNING Short Term: At the end of 30 mins of nursing intervention patient will maintain temperature within normal range

INTERVENTIONS Independent: y Provide tepid sponge bath y Wrap extremities with blanket Increase fluid intake of 1.5 to 1L/day Maintain bed rest

RATIONALE -

EVALUATION

Short Term: At the end of 30 minutes To reduce body heat and promote of nursing intervention the patient was able to heat loss by evaporation to maintain temperature minimize shivering within normal range To promote hydration

Objective: y Temperature 38.3 C y Flushed Skin y Warm to touch y Muscle rigidity y Restleness and irritable y Increased RR - 30

Long Term: At the end of 3 hours of nursing intervention patient will be able to understand the importance of treatment and promote normothermia

To reduce oxygen demand

Collaborative: Administer antipyretics as ordered

Long Term: At the end of 3 hours of nursing intervention the patient was bale to understand importance of treatment and be free of hyperthermia

To restore normal body temperature

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ASSESSMENT Subjective: Gi uboha na siya , galisod ug ginhaw tungod ana tapos naai plema na dili gagawas as verbalized by the mother

DIAGNOSIS Ineffective airway clearance related to excessive mucus production

PLANNING Short Term: After 30 minutes of nursing intervention patient will demonstrate reduction of congestion

INTERVENTIONS Independent: y Elevate head of the bead

RATIONALE To take advantage of gravity decreasing pressure on the diaphragm and enhancing draingage To liquify secretions and omprove lung function

y Objective: y Difficulty in expectorating sputum y Wheezing in expiration in both lung fields y Restless and irritable y Wide-eyed y Cough Long Term: After 1 hour of nursing intervention patient will be able to maintain adequate patent airway Increase fluid intake at least 1.5 to 1L/day within level of tolerance

EVALUATION Short Term: After 15 minutes of nursing intervention the patient was free of congestion with clear breath sound and improved oxygen exchange

Collaborative:

Long Term: After 3 hours of nursing intervention the patient was able to contunuosly expel white or clearer secretions

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ASSESSMENT Subjective: Nagsakita na iya tiyan pag-daun malibang o bisan dili gud. Mukalit lang ug sakit as verbalized by the mother

DIAGNOSIS Acute Pain related to abdominal cramping and irritation

PLANNING Short Term: After 30 minutes of nursing intervention patient will - Report relief from pain

INTERVENTIONS Independent: y Note on childs age and developmental level and current condition

RATIONALE -

EVALUATION Short Term: The levelo of the childs After 30 minutes of nursing intervention the development will patient appeared calm determine how he / and reported relief of she handles a painful pain. situation , what are his/her manifestations and the current condition may be the cause of the pain experienced.

Objective: y Guarding behavior y Protective gestures y Facial mask : Grimacing y Restless and irritable y Diaphoresis y Reduced interaction with people and environment y v/s: T: P: R:

Long Term: After 3 hours of nursing intervention patient will be able to maintain absence from pain.

Determine and document presence of possible pathophysiology and psychological causes of pain Assess for referred pain To help determine possibility of underlying condition or organ dysfunction requiring treatment

Long Term: After 3 hours of nursing intervention the patient was able to continuously manifest absence of pain.

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Use the facial expression pain rating scale

To determine intensity of pain

Monitor skin color , temperature and vital signs Encourage diversional activities like playing with toys etc. Provide comfort measures, quiet environment and calm activities

These are altered in acute pain and to provide a baseline data To promote non pharmacologic pain management To enhance level of anxiety and fear

Use puppets to demonstrate procedure for child y Encourage adequate rest periods Dependent: y Administer analgesics as indicated to y

To divert childs attention

To prevent fatigue To maintain acceptable level of pain. -

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