NURSING CARE PLAN

Date/ Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention Evaluation
Shift
Subjective: P Risk for Deficient fluid Short Term: Independent: Short Term:
Oct. Verbalized,masakit pa H volume r/t excessive After 20-30 Evaluated pattern After 20-30
3, ang aking tiyan. Y losses through minutes of of defecation. minutes of
2017 Watcher verbalized, S frequent diarrhea as providing nursing R. Defecation pattern providing
,kahapon pa sya I evidenced by dry skin, intervention: will promote nursing
7-3 nagsimulang O pale lips and Lost body immediate treatment. intervention:
dumudumi at ika-2 L conjunctiva and fluids will be Assessed vital Goal met as
beses syang dumumi O watchers verbalization replaced. signs evidenced
ngayong araw at basa G R. hypotension by lost
parin eto masyado. I R: Diarrhea is an Long Term: (including postural), body fluids
C increase in the After 2-4 hours of tachycardia, fever was
frequency, volume and proving nursing can indicate response replaced
Objectives: NEED fluid content of stool interventions: to or effect of fluid with PLR
VS taken as follows: that may cause fluid The patient loss. 500cc fast
o T: 35.8C E and electrolyte will maintain Encouraged to drip for
o P: 109 bpm L imbalance due to the adequate fluid maintain bed rest 210cc and
o R: 28 cpm I fluids that was lost volume as and avoidance of changed to
o BP:100/70mmH M through watery stool evidenced by exertion. bottle #2
g I which can be risk for good skin R. To decrease stress D5LR 500cc
Dry skin N deficient fluid volume. turgor, moist and anxiety that can regulated @
Skin turgor - 2 sec A skin, pinkish aggravate diarrhea. 50cc/hr.
Capillary refill - 2 sec T Source: conjunctiva Encouraged to
Pale conjunctiva and I Nursingcrib (2017). and lips, and increase oral fluid
O Mursing Care Plan balance intake
lips intake.
N Diarrhea. Retrieved on and output.
Restlessness noted R. increase fluid
Irritability noted August 29, 2017 from: intake replaces fluid
Facial grimace http://nursingcrib.co lost in liquid stools.
m/nursing-care- Encouraged to eat
plan/nursing-care- foods rich in
plan-diarrhea/ potassium such
as banana.
 R. when a client
experience diarrhea,
the stomach contents
which is high in
potassium get
flushed out of the
gastrointestinal tract
into the stool and out
of the body, resulting
in hypokalemia.

Collaborative:
Administered
parenteral fluids
given by NOD as
ordered.
R. Maintenance of
bowel rest requires
alternative fluid
replacement to
correct losses.
Administered
medications
given by NOD as
ordered:
antidiarrheal and
antibiotics.
R. To reduce fluid
losses in the intestine
and to prevent
further spread of the
bacteria.