Cues Nursing Rationale Objective/Goal Nursing Rationale Evaluation

Diagnosis Intervention
Within 4 hours of Independent: Within 4 hours of
Subjective: nursing intervention nursing intervention
P= fluid volume Irritation of the the the patient will : 1.) Monitor vital signs For baseline the patient :
“limang beses
data
na ako deficit gastro intestinal > Lessen painful >verbalizes that
tract might lead to symptoms. paiful symptoms is
sumusuka at
2.) Encourage patient These lessen
nilalagnat pa E= related to vomitting because
>The client appear to rest in supine measures
ako.” As vomitting & some the bodys’s relaxed through position w/ a warm promotes GI >condition of the lips
verbalization & heating pad in the relaxation & and mouth are
verbalized by dehydration due response is to
gestures. abdomen. reduce normal
the client. to Acute expel the foreign cramping.
body in the >Episides of > Verbalize
gastroentiritis
vomitting will understanding of
system subside 3.) Encourage Small amounts causative factors &
S= “5times ako frequent intake of of lfluids do not rationale for
Objective: >Lips and eyes will small amounts of cool distend the treatment regimen.
sumuka tsaka
be back to normal clear liquids: 30-60 gastric area and
• Had
may konting mL every ½ to 1 hr. thus do not > Demonstrate
several aggravate appropriate behavior
lagnat.”
symptoms. to assess w/
episodes of
resolution of
vomitting Reduction of causative factors.
4.)Encourage the
anxiety & fear & (e.g. proper food
• Dry and SOURCE: patient to verbalize &
promote preparation or
give appropriate
chaped Nursing care Plan relaxation. avoidance of
information.
irritating foods.
lips & Documentation

• sunken 4th Edition by

Dependent:
eyes Lynda Juall
Administer Relieve pain, GOAL met.
Carpenito-Moyer..
medications enhance
page 252. (Prevacid & comfort &
Ambroxol) as ordered promote rest..
by a physician