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  • NCP 1

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    Mary Antonette Adriano Enriquez
    820 views3 pages
    The document provides an assessment, diagnosis, planning, intervention, and evaluation for a client presenting with vomiting and diarrhea. The client's mother reported the symptoms started on Wednesday morning. Upon examination, the client had an increased heart and respiratory rate with hyperactive bowel sounds and pale skin. The diagnosis inferred the symptoms were likely due to an infection causing inflammation in the intestines. Short term goals included reducing stool frequency and long term goals involved maintaining normal weight and understanding preventative measures. Nursing interventions involved monitoring bowel sounds and output, providing fluids and electrolytes, and administering prescribed medications. The evaluation showed the interventions were effective in returning the client's bowel function and weight to normal.

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    The document provides an assessment, diagnosis, planning, intervention, and evaluation for a client presenting with vomiting and diarrhea. The client's mother reported the symptoms started on Wednesday morning. Upon examination, the client had an increased heart and respiratory rate with hyperactive bowel sounds and pale skin. The diagnosis inferred the symptoms were likely due to an infection causing inflammation in the intestines. Short term goals included reducing stool frequency and long term goals involved maintaining normal weight and understanding preventative measures. Nursing interventions involved monitoring bowel sounds and output, providing fluids and electrolytes, and administering prescribed medications. The evaluation showed the interventions were effective in returning the client's bowel function and weight to normal.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    820 views3 pages

    NCP 1

    Uploaded by

    Mary Antonette Adriano Enriquez
    The document provides an assessment, diagnosis, planning, intervention, and evaluation for a client presenting with vomiting and diarrhea. The client's mother reported the symptoms started on Wednesday morning. Upon examination, the client had an increased heart and respiratory rate with hyperactive bowel sounds and pale skin. The diagnosis inferred the symptoms were likely due to an infection causing inflammation in the intestines. Short term goals included reducing stool frequency and long term goals involved maintaining normal weight and understanding preventative measures. Nursing interventions involved monitoring bowel sounds and output, providing fluids and electrolytes, and administering prescribed medications. The evaluation showed the interventions were effective in returning the client's bowel function and weight to normal.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Subjective: Nutrition Short term goal: Independent: • Inflammation or After all the
    “nakailang suka at imbalanced less After 1 hours of •Auscultate bowel irritation of the nursing
    dumi na siya nung than body nursing sounds, noting intestine may be interventions the
    myerkules ng requirements intervention the absence or accompanied by client’s mother
    umaga kaya related to client was able to hyperactive intestinal was able to report
    isinugod na namin insufficient fluids report that there is sounds. hyperactivity, that the client was
    siya dito sa and electrolyte. reduction in diminished water maintaining her
    hospital” frequency of absorption and normal weight and
    verbalized by the Inference: stools. diarrhea. able to free from
    mothers patient the illness.
    Vomiting are not Long term goal:
    Objective: diseases, but After 1 week of • Eliminate smells • Reduces gastric
    T: 36.8 rather are nursing from the stimulation and
    RR: 31 bpm symptoms of interventions the environment. vomiting
    PR: 125 bpm many different client was able to response.
    conditions, such maintain her body
    • Hyperactive as infection weight and • Avoid foods that •Might increase
    bowel sounds. ("stomach flu"), understand all the might cause or abdominal
    food poisoning, precautionary exacerbate cramping.
    • Pale conjunctiva and migraines. measures to abdominal
    and mucus Nausea and prevent in getting cramping like
    membrane. vomiting can the illness. caffeinated
    sometimes be beverages,
    • frequent watery symptoms of more chocolate, orange
    stools serious diseases. juice.

    Diarrhea is the • Measure • Provides


    passage of loose abdominal girth. quantitative
    and watery stools evidence of
    (more than 3 changes in gastric
    bowel movements or intestinal
    per day) often distention.
    associated with • Observe skin or • Hypovolemia,
    gassiness, mucous fluid shifts and
    bloating, and membrane nutritional deficits
    abdominal pain. dryness, and contribute to poor
    turgor. Note skin.
    Ref. mosby’s peripheral edema.
    dictionary.
    •Assess abdomen •Indicates return
    frequently for of normal bowel
    return to softness, function and
    appearance of ability to resume
    normal bowel oral intake.
    sounds, and
    passage of flatus.

    Dependent:
    • Monitor protein, •Reflects organ
    prealbumin or function and
    albumin, glucose, nutritional status
    nitrogen balance and needs.
    as indicated.

    • administration of • to be free from


    medication as pain and will help
    prescribe by the for the cure of the
    physicians illness.

    Reference :
    Reference :
    Fundamentals by
    kozier and nanda nanda

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