Nursing Diagnosis Acute abdominal pain r/t increased ketoacid production SUBJECTIVE DATA: Ang sakit po ng tiyan ko,

as verbalized by the patient. OBJECTIVE DATA: pale (+) guarding behavior (+) facial grimace Localizes pain (epigastric area) Pain scale: 8/10 (10 as the highest and 1 as the lowest) ABG result: metabolic acidosis Vital signs: BP: 110/80 mmHg RR: 27 cpm PR: 115 bpm Temp: 37.3 C

Nursing Goal After 30 minutes of nursing interventions, the patient will verbalize relief of pain with a pain scale of 3-4 out of 10 from 8/10 and without any guarding behavior.

Nursing Intervention INDEPENDENT: -Assessed vital signs and recorded. -Obtained patients assessment of pain such as location, characteristics, onset/duration, frequency, quality and intensity. -Acknowledged the pain experience and conveyed acceptance of patients response to pain. -Observed non-verbal cues/pain behaviors such as facial expression and how patient holds his body. -Provided comfort measures by rendering warm compress. -Encouraged to do relaxation techniques deep breathing such as deep breathing. -Encouraged diversional activities such as listening to radio or watching TV. -Encouraged adequate rest. DEPENDENT: -Given Omeprazole 40 mg TIV STAT as ordered by attending physician.

Evaluation After 30 minutes of nursing interventions and medical management the patient verbalized, hindi na po masyadong masakit yung tiyan ko maam, and with a pain scale of 4/10.

Goal met.

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Nursing Diagnosis Fluid volume deficit related to increase in urine output as evidenced by intake of 1,500 ml and output of 3,000 ml. SUBJECTIVE DATA: Nagsusuka at laging nauuhaw ang anak ko, as verbalized by the mother. OBJECTIVE DATA: -sunken eyeballs -dry skin -poor skin turgor -cold clammy skin -sudden weight loss - intake- 1, 500 ml - output- 3,000 ml. - vomits 3x during admission.

Nursing Goal SHORT TERM GOAL: After 8 hours of nursing interventions, E.B. will demonstrate adequate hydration. LONG TERM GOAL: After 4 days of nursing intervention, E.B. will maintain fluid volume at functional level as evidenced by adequate urinary output.

Nursing Intervention INDEPENDENT: -Monitored vital signs. -Monitored temperature, skin color and moisture. -Assessed peripheral pulses, capillary refill, skin turgor and mucous membrane. -Monitored input and output. Noted specific gravity. -Monitored weigh daily. -Maintained fluid intake at least 1,500 ml/day. -Promoted comfortable environment. Covered patient with light sheets. COLLABORATIVE: -Administered fluids as indicated. -Reassessed the aforementioned nursing interventions.

Evaluation After 8 hours of nursing interventions, E.B. demonstrated adequate hydration.

After 4 days of nursing intervention, E.B. maintained fluid volume at functional level as evidenced by adequate urinary output.

Goal met.

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Nursing Diagnosis Activity intolerance related to body weakness as evidenced by difficulty in carrying himself alone. SUBJECTIVE DATA: Nanghihina sya at halos di na makatayo as verbalized by the mother.

Nursing Goal SHORT TERM GOAL: After 4 hours of nursing intervention, E.B. will participate in desired activities such as turning from side to side as necessary without any resistance, able to perform simple active exercises like extension and flexion of upper and lower extremities.

Nursing Intervention INDEPENDENT: - Monitored presence of factors contributing to fatigue. - Assessed cardiopulmonary response to physical activity including vital signs before and after the activity. - Adjusted activities and assisted on ADLs. - Planned care to carefully balance rest periods with activities. - Promoted comfort measures and provide for relief of pain such as positive appraisal. - Planned for maximal activity within the clients ability. - Encouraged client to maintain positive attitude, suggest use of relaxation techniques such as visualization/ guided imagery.

Evaluation After 4 hours of nursing intervention, E.B. participated in desired activities such as turning from side to side as necessary without any resistance, able to perform simple active exercises like extension and flexion of upper and lower extremities. After 5 days of nursing intervention, E.B. demonstrated increase in activity tolerance like performing activities of daily living without any assistance.

OBJECTIVE DATA: - weak - supported by mother when rising up from bed. - with facial grimace when encourage to sit at bedside chair.

LONG TERM GOAL: After 5 days of nursing intervention, E.B. will demonstrate increase in activity tolerance like performing activities of daily living without any assistance

Goal met.

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