VIII.

PLANNING

NURSING CARE PLAN

Date Assessment Need Diagnosis Objective of Nursing interventions Evaluation

care
7/23/15 Subjective: Physiologic Activity Within 6 hours Encouraged complete Goal
7/3 need Intolerance of nursing care bed rest partially
Kapoy lage ilihok Related to client will be For patient met as
8:00 am akong lawas (Activity and Decreased able to identify recuperation and evidenced
maam mura mag Rest) HgB/HcT count negative factors recovery by:
walay kusug as secondary to affecting
verbalized Gastroenteritis activity Provided enough air Verbalized
intolerance and coming from the feeling
Objective: low hgb and hct reduce their window energized
-Weakness level effects as To monitor patients and is able
evidence by: response to activities to relax.
-Restlessness decrease
oxygen being -Get enough Developed and adjust
-Activity delivered to the rest simple activity like
Intolerance tissues of the brushing his teeth
body -can tolerate To prevent
-Fatigue activities overexertion
body will
-Decreased HgB increase its -HgB count to Assisted client with
count -123mg/L demand of normal range activity
oxygen To protect patient from
-Decreased HcT -HcT count to injury
count which results normal range
0.37 then to fatigue. Promoted comfort
 -Verbalize measures on the
there will be willingness to activity
fast comply to To prevent over-
consumption of treatment exhaustion
ATP leading to regimen
weaker Ascertained ability to
contractions stand and move about
thus causing degree of assistance
muscle To determine current
weakness. status and needs

And if the Provided health

patient has teaching on the client
muscle regarding the
weakness there organization and time
will be activity management
intolerance. technique to prevent
while on activity
To enhance patient
ability to participate in
activity
Date Assessment Need Diagnosis Objective of care Nursing Intervention Evaluation

7/23/15 Subjective: Learning Knowledge After an hour of -Provided an environment Goal met
7/3 Nagkaon need Deficit nursing care client that is conducive to learning. As
7:30 am raman ko ug related to will be able to exhibit To let the patient feel at ease evidenced
itlog atu (health Inaccurate increased in interest with the environment by:
maam dayun teachings) informationand assume
gikalibanga secondary responsibility for own -Determined clients reiterating
nako as to learning and begin to ability to learn the
verbalized look for information to deliver the information information
Gastroente as evidence by : effectively given
Objectives: ritis -States the related to
-Confused of advantages of having -Be alert to signs of her
the questions the right knowledge avoidance condition
on the situation May need to allow client to and stated
-Repeats the suffer the consequences of the
question -Clearly understands lack of knowledge before willingness
twice the questions given client is to comply to
and give accurate ready to accept information. her
-Inaccurate answers regimens
follow- -Provided information
through of -Accurate follow- relevant to the situation
instruction through of to be specific and precise
instructions
-Identified information that
-Verbalized needs to be remembered
willingness to comply (cognitive).
to treatment regimen To be precise in giving
information
Date Assessment Need Diagnosis Objective Nursing INTERVENTIONS Evaluation
of care
11/23/15 Subjective: Physiologi Within 8 -Emphasized importance Goal
Imbalanced
7/3 Dili kayo ko c need hours of of well-balanced, nutritious partially
Nutrition: Less than nursing intake. met as
ganahan mukaon Body Requirements
7:15 am (Nutrition) care client To encourage good evidenced
maam oy as due to insufficient will be able nutrition by:
verbalized to maintain
intake and
balanced - Prevent/minimize verbalized
excessive output s/t nutrition as unpleasant odors/sights. Understan
Objective:
Gastroenteritis evidence may have a negative ding of
by: effect on appetite/eating good
-Weakness Gastroenteritis nutrition
-Normal -Noted total daily intake, and is
-Diarrhea digestive and laboratory patterns and times of having a
3x absorptive Values eating good
malfunction to reveal changes that appetite
-Hyperactive
-Normal should be made in clients
bowel sounds 25- affects the persons bowel dietary intake.
28 interest to food or movement
intake -Promoted pleasant,
-Low Potassium
-good relaxing environment,
level while the output is appetite including socialization
increasing because when possible
2.95mmol/L of the increased to enhance intake
bowel movement
-Low Calcium
level imbalanced nutrition
 0.57 mEq/L

DATE ASSESSMENT NEED Nursing Diagnosis Objective Nursing Evaluation

of Care Interventions
11/23/1 Subjective: Physiolo Fluid volume deficit Within -Encouraged oral fluid intake of Goal
5 gic and electrolyte less 4hours of fluids containing electrolyte partially
Cge jud ko ug needs than nursing For fluid replacement met
7/3 body requirements care client As
bawas maam
Fluids related to excessive will be able -Restricted solid food intake evidenced
9:00 am tapos Basa jud
and fluid output secondary to maintain To allow for bowel rest and by:
akong Electro to Acute normal reduce intestinal workload
ginagawas na lytes Gastroenteritis fluid and dry oral
electrolyte -Limit caffeine and high-fiber mucosa
hugaw maam
Volume depletion, s volume foods and so as fatty foods and dry
as verbalized or extracellular fluid as To prevent gastric irritation lips was
(ECF) evidence not noted
Objective: by: -Promoted use of relaxation
volume contraction technique bowel
-Hyperactive
occurs as a result of -Normal To decrease stress and anxiety sounds is
bowel sounds loss of total body Bowel that can aggravate diarrhea 18
25-28 sodium. sounds w/
-poor skin turgor 5-15 -Recommended products like
Causes include clicks/min yogurt and cultured milk
-Weakness
vomiting, excessive To restore normal flora
-Dry lips and sweating, diarrhea, -Skin
oral mucosa burns, diuretic use, turgor -Assessed general condition and
and kidney failure intact vital signs
-Diarrhea 3x
For baseline data
.Clinical features -Dry Oral
includes diminished Mucosa -Auscultated abdomen
skin turgor , dry not noted For presence, location, and
mucous characteristics of bowel sound
membranes -Absence
,tachycardia , of Diarrhea
hypotension.