Nursing Care Plan

Assessment Subjective: hindi pa rin nagdudumi ang anak ko as verbalized by the patients mother

Diagnosis Risk for constipation related to inability to eliminate wastes as manifested by patients habitual eating of bananas and recent environmental changes

Planning After 4 hours of nursing intervention patient will be able to maintain usual pattern of bowel functioning

Intervention -instruct in/encourage balanced fiber and bulk in diet

Rationale -improve consistency of stool and facilitate passage through the colon -to promote moist/soft stool

Evaluation After 4 hours of nursing intervention patient was able to maintain usual pattern of bowel functioning

Objective: -recent environmental changes -usually eat bananas

-promote adequate fluid intake, including water and highfiber juices -encourage activity/exercise within limits of individual ability

-to stimulate contractions of the intestines

Assessment Subjective: hindi gaanong umiinom ang anak ko ng tubig as verbalized by the patients mother Objective: -dry lips -decreased urine output -pt. drinks water not more than half of his tumbler (210mL)

Diagnosis Fluid volume deficit related to inadequate free water supplementatio n as manifested by dry lips, decreased urine output and pt drinks water not more than half of his tumbler (210mL)/

Planning After 4 hours of nursing intervention patient will be able to maintain fluid volume at a functional level as evidenced by dry lips, and decreased in urine output

Intervention -determine effects of age

Rationale -infants and children have a relatively high percentage of total body water, are sensitive to loss, and are less able to control their fluid intake -to determine the patients level of hydration

Evaluation After 4 hours of nursing intervention patient was able to maintain fluid volume at a functional level as evidenced by dry lips, dry tongue and decreased in urine output

-monitor Input and Output -determine current weight -establish 24hourfluid replacement needs and routes to be used

-prevents peaks/valleys in fluid volume

Assessment Subjective: pinapakain siya ng saging kahit bawal as verbalized by the patients relative

Diagnosis Knowledge deficit related to information misinterpretatio n as manifested by inaccurate follow-through of instruction

Planning After 4 hours of nursing intervention patient will be able to perform necessary procedures correctly and explain reasons for the actions

Intervention -be alert to signs of avoidance

Rationale -may need to allow client to suffer the consequences of lack of knowledge before client is ready to accept information

Evaluation After 4 hours of nursing intervention patient was able to perform necessary procedures correctly and explain reasons for the actions

Objective: -inaccurate follow-through of instruction

-state objectives clearly in learners terms -to meet learners needs -determine clients method of accessing -to facilitate information and learning include in teaching plan -provide written information/guidel ines for client to refer to as necessary -reinforces learning process