1.

KARUNIATI ISTIARI DEWI

2. SUCI DWI AMBARWATI
NURSING CARE PLAN (NCP)
CAUSE
A 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
NO DATE DATA PROBLEM ETIOLOGY
1 May, 6,
2014 08.00
a.m
SD : Patient say had
defecation 10 times a day
with liquid consistency,
yellow colour, and pulp.
OD :
a. BP : 90/60 mmHg
b. P : 112 x/minutes
c. Poor skin turgor
d. Decreased urine
production
e. Pale mucosa
Deficient Fluid
Volume
Active fluid
volume loss
2. May, 6.
2014 08.20
a.m
SD : Patient say got fever.

OD :
a. T : 39 C
b. P : 112 x/minute
c. RR : 25 beats/minuts
Hyperthermia Disease
(diarrhea)
3. May, 6.
2014 08.30
a.m
SD : Patient say vomiting 5
times a day.

OD :
a. his weight was 8.5 kg
b. Decreased appetite
c. Pale mucous membranes
Imbalance nutrition
: less than body
requirements
Biological
factor
NURSING OUTCOMES CLASSIFICATION
NO DATE DIAGNOSIS LABEL NOC INITISI
AL
1. May, 6
2014
08.40 a.m
Deficient Fluid
Volume related to
Active fluid volume
loss

After doing nursing
implementations 3x 24 hours, the
client will achieve FLUID BALANCE
(0601), as evidenced by :
a. Blood pressure will increase
from level 2 to level 4
b. Radial pulse rate will increase
from level 2 to level 4
c. Skin turgor will increase from
level 2 to level 4


Dewi
and
Suci
2. May, 6
2014 09.00
a.m
Hyperthermia
related to disease
(diarrhea)
After doing nursing implementation for
2x 24 hours, THERMOREGULATION
(0800), as evidenced by:
a. Increased skin temperature will
increased from level 2 to level 4.
b. Radial pulse rate will increased from
level 2 to level 4.
c. Dehydration will increased from level
2 to level 4.
3. May, 6
2014 09.20
a.m
Imbalance
nutrition : less
than body
requirements
related to
biological factor.

After doing nursing implementation for 3x
24 hours, NUTRITION STATUS (1004), as
evidenced by:
a. Food intake will increased from level 2
to level 4
b. Energy will increased from level 2 to
level 4.

Dewi
and
Suci
Dewi
and
Suci
NURSING INTERVENTIONS CLASSIFICATION
NO DATE DIAGNOSIS LABEL NIC INITISI
AL
1. May, 6
2014
09.40 a.m

Deficient Fluid
Volume related to
Active fluid volume
loss

Fluid Management 4120 :
a. Monitor vital sign
b. Maintain accurate intake and
output record
c. Monitor ingested
d. Administer iv therapy, as
appropriate
e. give fluid as appropriate
f. Promote oral intake
g. Distribute the fluid intake
over 24 hours as appropriate
h. Consult physician if sign and
symptoms of fluid volume.

Dewi
and
Suci
2. May, 6
2014 10.00
a.m

Hypertherm
ia related
to disease
(diarrhea)

Temperature Regulation (3900) :
a. Monitor temperature at least every 2
hours as appropriate
b. Monitor blood pressure, pulse, and
respiration as appropriate
c. Monitor skin colour and temperature
d. Promote adequate fluid and nutrition
intake
e. Adjust environmental temperature to
patients needs
f. Administer antipyretic medication as
appropriate
Dewi
and
Suci
3. May, 6
2014 10.20
a.m

Imbalance
nutrition : less
than body
requirements
related to
biological
factor.


Nutrition Management (1100) :
a. Ascertain patients food preferences
b. Determine in collaboration with dietician as
appropriate
c. Provide patient with high protein, high
calorie
d. Weight patient at appropriate intervals
e. Monitor intake for nutrition
Dewi
and
Suci
Thank You
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