Lordgelyn Diane C. Viernes
BSN 3-2
Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data:
(not observed)
Objective Data:
Upon receiving the 5 y/o
patient (male), the
patient experiences loose
bowel movement and
vomiting. The vital signs
were taken;
T: 36.2
O2 Sat: 99
RR: 24
PR: 88
Increased RBC: 13.11
Decreased Lymphocyte:
0.15
Increased Segmenters
FA: (+) for Entamoeba Coli
Cyst
Risk for Fluid Volume
Deficit may be related to
diarrhea and vomiting
Short Term Goal:
After 30 minutes of
intervention, the patient
will be able to:
-the patient’s fluid
volume will be
maintained to normal
through parental
nutrition.
-maintain heart rate at 75
to 115 beats per minute
Long Term Goal:
After 1 hour of nursing
intervention the patient
will be able to have:
-Vomiting will subside
-have urine output of 30
to 40 ml per hour, and
normal skin turgor
After 5 hours of nursing
intervention, the patient
will excrete formed
stools.
Dependent Nursing
Intervention:
For the client who is
unable to take sufficient
oral fluids, consider the
need for hospitalization
and the administration
of parental fluids as
ordered
Administer antiemetic
medications as ordered
Administer oral
rehydration medications
Independent Nursing
Intervention:
Instruct the client to
monitor weight daily and
consistently with the
same scale, preferably
at the same time of the
day, and wearing the
same amount of clothing
Encourage regular oral
hygiene
Encourage increase fluid
intake of 1.0 to 1.2
liters/24 hours plus 120
ml for each loose stool in
children unless
Dependent Nursing
Intervention:
Fluids are needed to
maintain hydration
status. Determining the
type and amount of fluid
to be replaced and the
infusion rates will vary
depending on the
client’s clinical status
These drugs will reduce
vomiting and the risk of
fluid volume deficit
Oral hydrating solutions
(e.g., Rehydrate) can be
considered as needed. It
replaces fluid lost in the
liquid stool
Independent Nursing
Intervention:
The client w ith
gastroenteritis may
experience weight loss
from fluid loss with
diarrhea and vomiting.
Instruction facilitates
accurate measurement
and0assessment0provide
s useful data for
Short Term Goal:
After 30 minutes of
intervention, the patient
was able to:
-the patient’s fluid
volume is maintained to
normal through parental
nutrition.
-maintain heart rate at 75
to 115 beats per minute
Long Term Goal:
After 1 hour of nursing
intervention the patient
was able to have:
-Vomiting subside
-have urine output of 30
to 40 ml per hour, and
normal skin turgor
After 5 hours of nursing
intervention, the patient
excretes formed stools.
