XIV.

NURSING CARE PLAN

Cues

S> Isang lingo

na siya nag
dudumi.
Stated by the
s/o.
O> (+) LBM
With watery
stool, facial
grimace,
restlessness.
Dry skin, lips
and mouth
(+)poor skin
turgor

Nursing Diagnosis

Fluid Volume
Deficit r/t
Frequent Bowel
Movement

Scientific
Rationale

Objectives

Nursing Intervention

Invasion of
microorganisms
in the GI tract

GI irritation

Hyperactive
bowel sounds
and irregular
bowel movement

GI disturbances

Diarrhea

Excessive water
loss

Decreased fluid
volume in blood

Fluid Volume
Deficit r/t
Frequent Bowel
Movement

Short Term:
After 3-4 hours of
nursing
intervention the
patient will report
understanding of
treatment plan for
fluid volume
deficit

Assess skin turgor

and mucous
membranes

Poor skin
turgor and dry
lips are signs
of dehydration

Take vital signs

To establish
baseline data
To prevent
the risk of fluid
volume
imbalance

Long Term:
After 1-2 days of
nursing
intervention the
client will be able
to restore normal
fluid volume.

Monitor fluid
intake and output

Rationale

Weigh patient
daily.

Weight is the
indicator of
fluid status.

Maintain
adequate
hydration, increase
fluid intake

To prevent
excessive
dehydration &
to hydrate
patient
To promote
fluids and
electrolytes
and to prevent
dehydration

Administer IV
Fluid as ordered

Provide health
teachings:
Eating food high
in fluid content like
For hydration
watermelon, grapes
Encourage to eat
banana, rice, apple

Expected Outcome

After 1-2 days of

nursing
intervention
Patient will
maintain fluid
volume at
functional level
AEB well
hydrated, intake
is equal as
output, and
normal skin turgor
and bowel
movement.

XIV. NURSING CARE PLAN

and toast

Cues

Nursing
Diagnosis

Scientific
Rationale

Objectives

Nursing Intervention

Rationale

Expected
Outcome

XIV. NURSING CARE PLAN

S>
O> Poor skin
turgor,
(+) LBM
Serum sodium
level: 135
Potassium
level: 3.03
(+) weakness

Risk for
Electrolyte
imbalance
related to fluid
loss secondary
to diarrhea

Invasion of
microorganism
s in the GI tract

GI disturbances

Hyperactive
bowel sounds
and irregular
bowel
movement

Diarrhea

Fluid lost
contains Na
and potassium

Risk for
Electrolyte
imbalance

Short Term:
After 3-4 hours
of nursing
intervention,
patients will
verbalize
understanding
of the
importance of
electrolytes to
life.

Long Term:
After 1-2 days
of nursing
intervention
clients
electrolyte will
remain normal.

Establish nurse
patient interaction.

Take vital signs.

Monitor intake and
output
Administer IVF as
ordered
Administer prescribed
antibiotics
Monitor IV regulation
frequently
Increase fluid intake
Proper food handling
and waste disposal
Provide health
teachings such as:
Eating food high in
fluid content like
watermelon, grapes
Encourage to eat
banana, rice, apple and
toast
Avoid coffee and tea

To make patient
feel comfortable
with the presence
of the nurse.
To establish
baseline data.
To prevent severe
fluid volume deficit
To promote fluid
and electrolyte
balance
To kill or inhibit
bacterial infection
To prevent
pulmonary overload
To restore fluid
loss
To decrease
chances of
acquiring infections
For hydration
To treat diarrhea
and for stool
formation
To prevent further
dehydration

After episodes
of nursing
intervention,
the client will
report an
increase in the
energy field
AEB
performing
activities.

XIV. NURSING CARE PLAN

Cues
S> Masakit
ang aking
tiyan as
verbalized by
the patient
O> (+) facial
grimace
And irritability
Pain scale
5/10

Nursing
Diagnosis
Acute pain
related to
inflammation
in the
stomach and
intestine

Scientific
Rationale
Invasion of
microorganism
s in the GI tract

GI irritation and
inflammation

GI disturbanes

Acute pain

Objectives

Nursing Intervention

Short term:
After 3-4
hours of
nursing
intervention
client will
manifest
decrease in
pain.

Assess for location,

onset, duration,
frequency and severity
of pain.

Long Term:
After 2 days
of nursing
interventions
the patient
will be free
from pain
and
demonstrate
relaxation
skills.

Provide diversional
activities like
socialization
Create a quiet, no
disruptive environment
and comfortable
temperature when
possible
Administer analgesics
to maintain acceptable
level of pain as per
doctors order
Instruct client to
perform deep breathing
exercises (DBE)
Monitor effectiveness

Review factor that

aggravate or alleviate
pain
Encourage pain
reduction techniques
Provide adequate rest

Rationale
Pain is a subjective
experience and must be
described by the client in
order to plan effective
treatment
Helpful in establishing
diagnosis and treatment
needs
To reduce pain and
promote relief/comfort
To relieve stress and for
clients comfort
For clients comfort and
relief from pain
Comfort and a quiet
atmosphere promote a
relaxed feeling

To decrease pain
Deep breathing
exercises may reduce
pain sensation/ used in
pain management
To promote timely
intervention/ revision of
plan of care

Expected
Outcome
After series of
nursing
interventions the
patient will be
free from pain
and demonstrate
relaxation skills.

XIV. NURSING CARE PLAN

of pain medications

Cues

O> T- 37.7
The patient is
warm to touch c
(+)Flushing face
(+)teary eyes
(+)dry skin
(+)dry mouth

Nursing
Diagnosis
Hyperthermia
related to
invasion of
microorganism

Scientific
Rationale
Microorganism
invades the
digestive
system

The body
compensates
with the stimuli

The body
increases
temperature
due to infection

Fever occurs

Objectives
Short term
After 2-3
minutes of
nursing
intervention
the patient
and significant
others will
verbalize
understanding
regarding
health
teachings
Long term
After 2- 3
hours of
nursing
interventions
patients
temperature
will decrease
and maintain

Nursing
Intervention
Upkeep patient's
environment

Rationale

Monitor vital
signs, especially
temperature

To provide a
relaxing environment
for the patient
To evaluate
effects/degree of
hyperthermia

Apply TSB every

15 minutes

To decrease the
temperature

Administer
antipyretic
medication as
ordered

To decrease
temperature quickly

Provide health
teachings to the
significant other
such as:
-Proper TSB
-Increase fluid
intake

To be independent in
taking care and
maintaining the clients
temperature and
hydration status.

Expected
Outcome
After 2-3 hours
of nursing
intervention
patients
temperature
will decrease
and be relieved
from the
symptoms.

XIV. NURSING CARE PLAN

within normal
range.

Cues

Nursing
Diagnosis

Scientific
Rationale

Objectives

Nursing
Intervention

Rationale

Expected Outcome

XIV. NURSING CARE PLAN

O>
Weakness,
Restlessness
,
Physical
inactivity,
Fatigue

Activity
Intolerance r/t
weakness

GI disturbances

Hyperactive
bowel sounds
and irregular
bowel movement

Diarrhea

Fluid lost

Decrease
musculoskeletal
function

Restriction of
activities

After 3-4
hours of
nursing
intervention
the patients
will be able to
perform
simple
activities of
daily living.

Establish nurse- To gain client trust After series of nursing

patient
interventions, the
interaction
Patient will participate
willingly in necessary
Develop and
To prevent
or desired activities.
adjust simple
Overexertion
activity like
brushing his
teeth

Assist client with To protect patient

from injury
activity

Promote comfort To prevent overexhaustion

measures on the
activity

Ascertain ability
to stand and
move about
degree of
assistance

Encourage
complete bed
rest

To determine the
current status
and needs

For patient
recuperation
and recovery