NURSING CARE PLAN
NAME OF PATIENT: BABY BOY _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO. _
AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE _ WARD: NURSERY WARD _
DATE: MARCH 1, 2022 _
NURSING SCIENTIFIC NURSING
CUES OBJECTIVES RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTIONS
SUBJECTIVE/S: Risk for Deficient fluid volume is SHORT TERM INDEPENDENT Goal Was Met:
Her mother deficient fluid a state or condition in After 8 hours Monitor the vital - Tachycardia and
After 8 hours of
fever can indicate
stated that he have volume as which the fluid output of nursing signs. response to and effect nursing
a fever, diarrhea, evidenced by exceeds the fluid intake. interventions, the of fluid loss. interventions the
and vomiting after temperature of It occurs when water patient will be able Provide Tepid - Cool down the body patient was able to
feeding. She also 38.7 °C, and electrolytes are lost to: Sponge Bath. heat and reduce the
display stable vital
diarrhea, in normal body fluids. fever.
observed that he signs and adequate
vomiting, The gastrointestinal Display Monitor input and - Provide information
has a fast adequate in overall fluid balance output as evidence
heart rate of tract, polyuria, and output include all
breathing and fluid balance outputs such as and will be a guide for by temperature of
irritable. 165 bpm and a increased perspiration fluid replacement. 36.5°C, respiratory
respiratory are common causes of as evidenced emesis and stools.
by stable Assess skin turgor - To monitor the level rate of 55 cpm,
rate of 75 cpm. fluid loss. Active fluid of dehydration.
heart rate of 140
vital signs and capillary
OBJECTIVE/S: loss, such as vomiting refill. bpm, and vomit and
and diarrhea, is a risk and adequate
V/S taken as output. Encourage - Replacement for the diarrhea has
follows: factor, as is an increase increased fluid fluid loss in the body.
stopped.
in metabolic rate, such intake (continue
T – 38.7°C as fever. breastfeeding)
HR- 165 bpm Reference: Wayne, G., Weigh or per - Indicator of overall
(2021). “Deficient Fluid protocol. fluid and nutritional
RR – 75 cpm status.
Volume (Dehydration) DEPENDENT
Nursing Care Plan.” - Reveals imbalances
Monitor serial associated with fluid
Retrieved from electrolytes and electrolyte loss during
https://nurseslabs.com/deficient- metabolic panel. vomiting and diarrhea.
fluid-
volume/#:~:text=Deficient%20Fl
Administer IV - Replacement of the
fluids and fluid loss in the body
uid%20Volume%20(also%20kno and treatment for fever
wn,the%20ECF%20in%20similar medications
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DRUG STUDY
NAME OF PATIENT: BABY BOY _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO. _
AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE _ WARD: NURSERY WARD _
DATE: MARCH 1, 2022 _
DOSE,
NAME AND FREQUENCY,
MECHANISM ADVERSE NURSING
CLASSIFICATION ROUTE, INDICATIONS CONTRAINDICATIONS
OF ACTION EFFECTS RESPONSIBILITIES
OF DRUGS DURATION OF
ADMINISTRATION
Generic Name: 120 mg It interferes It is used to treat Hypersensitivity Adverse effects BEFORE:
AMPICILLIN with cell wall infections or bacterial to any penicillin. include the Check the 10
q12 synthesis by infections such as Patients that’s following:
Brand Name: rights of
IV binding to Infections of have a condition Nausea medication
OMNIPEN penicillin- Gastrointestinal Tract, of infectious Diarrhea administration.
1 week binding Bacterial mononucleosis.
Classification: Vomiting
proteins meningitis/septicemia, Black
PENICILLIN (PBPs), or Soft Tissue AFTER:
hairy
BETA-LACTAM inhibiting cell Infections.
ANTIBIOTIC
tongue Monitor the
wall Rashes common
peptidoglycan
adverse effects
synthesis, and
of the drug and
inactivating
notify the
autolytic
physician if
enzyme
any of it occur.
inhibitors.
Tell to the
guardian the
possible side
effects of the
drugs.
DRUG STUDY
NAME OF PATIENT: BABY BOY _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO. _
AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE _ WARD: NURSERY WARD _
DATE: MARCH 1, 2022 _
DOSE,
NAME AND FREQUENCY,
MECHANISM ADVERSE NURSING
CLASSIFICATION OF ROUTE, DURATION INDICATIONS CONTRAINDICATIONS
OF ACTION EFFECTS RESPONSIBILITIES
DRUGS OF
ADMINISTRATION
Generic Name: 12 mg It involves It is used to treat Hypersensitivity to the The adverse BEFORE:
GENTAMICIN inhibition of or prevent drug or have a serious reactions include Check the 10
OD bacterial serious infections toxic reactions is the following:
Brand Name: rights of the
IV protein caused by contraindicate. Nausea medication
GARAMYCIN synthesis by susceptible Vomiting administration.
1 week binding 30s bacteria. It also
Classification: Stomach DURING:
ribosomes. for reducing the upset
AMINOGLYCOSIDE development of Inject or
Ringing
ANTIBIOTICS drug-resistant infused slowly.
or roaring
bacteria. sounds in AFTER:
the ears
Monitor the
Dizziness
common
adverse
reactions of the
drug and notify
the physician if
any of it occur.
Tell to the
guardian the
possible side
effects of the
drugs.
DRUG STUDY
NAME OF PATIENT: BABY BOY _ NAME OF STUDENT: CRISTYL SHINE G. BARIAO. _
AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE _ WARD: NURSERY WARD _
DATE: MARCH 1, 2022 _
DOSE,
NAME AND FREQUENCY,
MECHANISM ADVERSE NURSING
CLASSIFICATION ROUTE, DURATION INDICATIONS CONTRAINDICATIONS
OF ACTION EFFECTS RESPONSIBILITIES
OF DRUGS OF
ADMINISTRATION
Generic Name: 100 mg It is a p- It is used to Hypersensitivity to the It rarely cause side BEFORE:
aminophenol relieve pain and drug and have a severe effects but it may
PARACETAMOL PRN give serious
Check the 10
derivative that high temperature. hepatocellular rights of the
Brand Name: has analgesic A painkiller that insufficiency. allergy reactions
Oral such as: medication
BIOGESIC Suspension/PO and antipyretic treat fever and administration
properties. It is headache. Skin
Classification: rashes DURING:
thought to
ANALGESIC produce (itchy, red, Give the
analgesia by swollen,
ANTIPYRETICS medication
blistered or
centrally slowly to avoid
peeling
inhibiting skin) aspiration.
prostaglandin Wheezing AFTER:
synthesis. Tightness
of chest or Monitor if
throat there’s any
Trouble allergic
breathing reactions.
Swelling Notify the
mouth, physician if
face, lips, any of it
tongue, or occurred.
throat.
