Organization of Data

Nursing Diagnosis

Expected Outcome (Goals)

Nursing Interventions/Strategies

Evaluation

Subjective (S): (mother)

·         Abdominal pain

·         Vomiting

·         Loose stool

·         No urine with the last eight hours

·         Cold skin

Objective (O):

·         Facial grimace

·         Irritability

·         Dry skin

·         Cracked lips

·         Decreased skin turgor

·         Redness of the skin in the perineal area

·         Dry mucous membrane

·         The patient does not produce tears on crying

·         Acute pain related to the medical condition as evidenced by abdominal pain, facial grimace, and irritability (HIGH)

·         Fluid volume deficit related diarrheal stools as evidenced by lack of urine for past 8 hours, decreased skin turgor and Patient not producing tears on crying (HIGH)

·         Impaired skin integrity related to persistent passing of loose   stools as evidenced by dry skin, cracked lip and dry mucous membrane (INTERMEDIATE)

·         The child will report a decrease of pain within 30 minutes

·         The patient will demonstrate relaxation skills and free of pain within 1 hour

·         The child will be hydrated and initiation of oral drinks will be done within  24 hours

·         The child will not experience skin break down and cracks within 24 hours

·         Monitor for the need for pain relief

·         Removal of additional stressors or any source of discomfort as much as possible

·         Determination of the appropriate pain relief method

Rationale:

·         Monitoring of the pain will help I early identification of a need to relieve pain which might reduce the amount of analgesic needed for the child

·         Clients may have decreased the ability to tolerate painful stimuli in the cases where there is additional stressors resulting from the environment, intrapsychic and intrapersonal factors (Wayne, 2016a).

·         Patients with acute pain are usually administered with non-opioid analgesics unless it is contraindicated for the patient

·         Monitor fluid input and output and keeping proper documentation of the information

·         Monitoring of the weight of the child and comparing with the one taken during the admission

·         Assess the level of consciousness of the child, the skin turgor, membranes, the color of the skin and temperature, capillary refill and eyes every four hours

Rationale:

·         Monitoring input and output will help in determining if production exceeds input. An extended period of urine output might indicate signs of reduced renal function (Wayne, 2016b).

·         Monitoring of the weight of the child will help in the determination of the degree of dehydration. It will also help in monitoring the effective of rehydration process being done

·         Assessing the elements will help in identifying the degree of hydration of the child.

·         Assess the skin of the perineal area for signs of skin breakage including the rectum or if there is irritation.

·         Change diapers two hourly or as need be

·         Application of A & D ointment four times or more each day

Rationale:

·         Early assess, and provision of necessary services can reduce chances of the condition worsening.

·         Changing diapers every two hours reduces contact that occurs between the skin and chemical irritants that are present in the urine and stool (Wayne, 2018).

·         The ointment protects intact or reddened skin and act as a barrier and from being excoriated (Belleza, 2018).

The child reported a decrease in pain, and she demonstrated relaxation. The goals were met. However, the nursing care plan will be continued to facilitate comfort

The child has a normal fluid volume which will be shown by physical examination and lab evaluation. The goal is met.

The nursing care plan should be discontinued

There was a significant recovery and reduction of redness and cracking. The goal was partially met — nursing care plan to be continued.