ASSESMENT NSG. DIAGNOSIS NSG.
GOAL AND INTERVENTION RATIONALE EVALUATION
OBJECTIVES
1)Ask the mother of 1) Eating contaminated 1) Vital signs will
“Nagtatae at nag Potential for Prevent the spread of the patient about a foods or drinking return to normal limits
susuka ang anak ko infection: the infection recent history of: contaminated water for age.
ng mga 6 na beses Presence of may predispose the V/S
na” as verbalized by infectious Drinking contaminated client to intestinal T= 36.5 C
the mother. organisms as water. infection. PR= 90 bpm
manifested by Eating food RR= 26 bpm
watery loose stool inadequately cooked. 2) Fluid and electrolyte 2) The child’s bowel
-Weak in Appearance Ingestion of imbalances can alter function will returns
-Watery stools unpasteurized dairy vital body functions. to normal.
-(+) sunken eyeballs products.
--(+) Vomiting 3) Aids in the
-(+) sunken 2) Obtain baseline diagnosis and in 3) Infection will not
fontanelle vital signs and monitor monitoring the child’s spread to others
-(+) high fever every 2–4 hours. status.
4) Stool culture will
Vital Signs: 3) Observe stools for 4) Frequent defecation negative after nursing
PR: 87 bpm amount, color, and some infectious implementation.
RR: 22 bpm consistency, odor, and organisms can cause
Temp: 37°C frequency. bleeding.
5) Rapid notification of 5) Family will
4) Test stools for demonstrate and
the physician will
occult blood. understand child’s
facilitate treatment.
care and management.
5) Monitor results of 6)Helps prevent
stool culture and 6) Families will
transmission of
sample for ova and comply with
microorganisms.
parasites. instructions.
7) Prevents exposure
6) Support and 7) Families will
of other patients and
Educate the family comply with
staff.
about hand washing instructions
before and after 8) The child may be 8) Child will take
contact with the child. weak, incontinent, prescribed
physically impaired, or nourishment.
7) Isolate the child anxious and require a
until the cause of the child in a comfortable,
diarrhea is determined. warm and well-
protected manner.
8) Apply diaper snugly
to reduce likelihood of 9) Provides necessary
fecal spread fluids and nutrients.
10) Ensures early
9) Administer intervention.
prescribed oral
rehydration and
intravenous solutions.
10)Notify the
physician if diarrhea
persists, stool
characteristics
change, or other
symptoms of
dehydration/electrolyt
e imbalance
occur
ASSESMENT NSG. DIAGNOSIS NSG. GOAL AND INTERVENTION RATIONALE EVALUATION
OBJECTIVES
“Nagtatae at nag 1) Will determine if output
susuka ang anak ko Fluid Volume -The child will remain 1) Monitor intake exceeds input. Long 1) The child will have
ng mga 6 na beses Deficit related to hydrated and and output. Be sure periods of time without normal fluid and
na” as verbalized by active fluid volume will begin to drink to document time of urine output can be an electrolyte balance as
the mother. loss fluids within 24 hours each voiding. early indicator of poor indicated by laboratory
of admission. And to renal function. A child evaluation and physical
Assess the progress of 2) Compare should produce 1 mL of examination.
-Weak in Appearance hydration. admission weight to urine/kg/hr.
-Watery stools Pre-admission 2)The degree of 2) Child will exhibits si
-(+) sunken eyeballs weight. Assess dehydration can be of adequate hydration.
--(+) Vomiting weight daily. determined by the
-(+) sunken fontanelle percentage of weight loss. 3)For a child will exhib
-(+) high fever 3)Assess level of Daily weights aid in no signs of distress
Vital Signs: consciousness, skin determining progress
PR: 87 bpm turgor, mucous toward rehydration. 4) For the therapies wil
RR: 22 bpm membranes, skin 3) Will determine degree maintain.
Temp: 37°C color and of hydration and adequacy
temperature, of interventions. 7) For the therapies wil
capillary, refill, eyes, 4)Vomiting frequently maintain
and fontanels every accompanies diarrhea and
four (4) hours. contributes to the
Child’s fluid loss.
4) Assess for 5) Less invasive than IV
vomiting. fluids. Provides
for replacement of essential
5) Provide oral fluid fluids and electrolytes.
and electrolyte 6) Use of IV replacement is
replacement solution based on
if able to tolerate. the degree of dehydration,
ongoing losses, insensible
6) Provide and water
maintain IV losses and electrolyte
replacement therapy,
as ordered. results
