University:
University of Alberta
Course:
NURS 124 | Foundations of Nursing I
Academic year:

2019
Views:

228

Pages:

2
Author:

gewoekerdodx

ASSESSMENT Subjective: “My whole tummy hurts” as verbalized by the patient. Objective: ● Presence of grimace and crying ● Dry skin ● Dry mouth ● Patient appears to be pale ● Patient is weak ● Skin is hot when EXPLANATION OF THE PROBLEM Diarrhea is the passage of loose and watery stools for more than 3 bowel movements per day. Often associated with gassiness, bloating, and abdominal pain. It may also be accompanied by nausea, vomiting, and fever. Diarrhea results to loss of body fluids and salts leading to dehydration of varying severity. Severe dehydration Nursing Care Plan OBJECTIVES NURSING INTERVENTIONS STO: After 4 hours of nursing intervention, that patient will be able to: A. Have a reduction in the frequenc y of stools. B. Achieve normal temperat ure RATIONALE EVALUATION Dx: Dx: STO: a. Assess skin turgor a. It is often used as a way to check for dehydration Within 4 hours of effective nursing interventions, the patient was able to: b. Observe and record stool frequency and characteristics of stools. c. Monitor vital signs every 30 minutes b. To determine if there are changes in the condition c. To obtain basic indicators of a patient’s health status a. reduce the frequency of stools b. Achieve normal temperatur e Tx: Tx: d. Perform TSB and provide loose shirt e. To lower temperature LTO: LTO: e. Promote bedrest f. To further improve touched ● VS of PR 91bpm, Temperature of 37.8 C, RR of 16CPM, and an SPO2 of 90% Nursing Diagnosis: Diarrhea related presence of toxins. may cause death especially in children. References: After 2 days of nursing intervention, the patient will be able to: A. be free of bacteria B. return the normal characte ristics and frequenc y of stools C. increase level of hydratio n f. administer medications as ordered patient health status GOAL MET: Edx: After 2 days of effective nursing interventions, the patient: Edx: g. Encourage the mother to give the patient foods high in potassium, such as bananas h. Educate the mother to let the patient drink between meal and avoid giving fatty foods g. To replace electrolyte h. drinking water rehydrates the body. fats and oils will likely to make the symptoms worse a. Was free of bacteria. b. Return the normal characteristics and frequency of stools c. Increase level of hydration