KARUNIATI ISTIARI DEWISUCI DWI AMBARWATINURSING CARE PLAN (NCP)

CAUSEA one-year-old boy was brought in ER. He said that he had defecation 10 times a day with liquid consistency, yellow colour, and pulp (+). He also said that he had vomiting 5 times a day, and got fever. The result of physical examination are this weight was 8.5 kg, he got decreased appetite, pale mucosa, poor skin turgor, BP : 90/60 mmHg, P: 112 x/minutes, RR: 25 beats/minute, and decreased urine production.

DATA ANALYSIS

NODATEDATAPROBLEMETIOLOGY1May, 6, 2014 08.00 a.mSD : Patient say had defecation 10 times a day with liquid consistency, yellow colour, and pulp.OD : BP : 90/60 mmHgP : 112 x/minutesPoor skin turgor Decreased urine production Pale mucosaDeficient Fluid Volume Active fluid volume loss

2. May, 6. 2014 08.20 a.mSD : Patient say got fever.

OD : T : 39 C P : 112 x/minuteRR : 25 beats/minutsHyperthermia Disease (diarrhea)3. May, 6. 2014 08.30 a.mSD : Patient say vomiting 5 times a day.

OD : his weight was 8.5 kgDecreased appetitePale mucous membranesImbalance nutrition : less than body requirementsBiological factor

NURSING OUTCOMES CLASSIFICATION

NODATEDIAGNOSIS LABELNOCINITISIAL1. May, 6 2014 08.40 a.mDeficient Fluid Volume related to Active fluid volume lossAfter doing nursing implementations 3x 24 hours, the client will achieve FLUID BALANCE (0601), as evidenced by :Blood pressure will increase from level 2 to level 4Radial pulse rate will increase from level 2 to level 4Skin turgor will increase from level 2 to level 4

Dewi and Suci

2.May, 6 2014 09.00 a.mHyperthermia related to disease (diarrhea)After doing nursing implementation for 2x 24 hours, THERMOREGULATION (0800), as evidenced by:Increased skin temperature will increased from level 2 to level 4.Radial pulse rate will increased from level 2 to level 4.Dehydration will increased from level 2 to level 4.3. May, 6 2014 09.20 a.mImbalance nutrition : less than body requirements related to biological factor. After doing nursing implementation for 3x 24 hours, NUTRITION STATUS (1004), as evidenced by:Food intake will increased from level 2 to level 4Energy will increased from level 2 to level 4.

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NURSING INTERVENTIONS CLASSIFICATION

NODATEDIAGNOSIS LABELNICINITISIAL1.May, 6 2014 09.40 a.mDeficient Fluid Volume related to Active fluid volume lossFluid Management 4120 :Monitor vital signMaintain accurate intake and output recordMonitor ingestedAdminister iv therapy, as appropriategive fluid as appropriatePromote oral intakeDistribute the fluid intake over 24 hours as appropriateConsult physician if sign and symptoms of fluid volume.Dewi and Suci

2. May, 6 2014 10.00 a.mHyperthermia related to disease (diarrhea)Temperature Regulation (3900) :Monitor temperature at least every 2 hours as appropriateMonitor blood pressure, pulse, and respiration as appropriateMonitor skin colour and temperaturePromote adequate fluid and nutrition intakeAdjust environmental temperature to patients needsAdminister antipyretic medication as appropriate

Dewi and Suci

3. May, 6 2014 10.20 a.mImbalance nutrition : less than body requirements related to biological factor.

Nutrition Management (1100) :Ascertain patients food preferencesDetermine in collaboration with dietician as appropriateProvide patient with high protein, high calorieWeight patient at appropriate intervalsMonitor intake for nutrition

Dewi and Suci

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