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by the mother. Objective data: Increased bowel sounds/pe ristalsis Frequent, and often severe, mushy stools Changes in stool color
Inference intestinal fluid output overwhelms the absorptive capacity of the GI tract damage to the villous brush border of the intestine, malabsorptio n of intestinal contents leading to an osmotic diarrhea, release of toxins that bind to specific enterocyte receptors release of chloride ions into the
Nursing Diagnosis Diarrhea related to presence of toxins as manifested by frequent elimination of mushy stools.
Goal/Plan After 3 days of Nursing Interventio n the patient’s parent/ watcher will: >Report reduction in frequency of stools, >return to more normal stool consistency .
Intervention/ Plan > Observe and record stool frequency, characteristics , amount, and precipitating factors. > Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products
>Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria. >Observe for excessively dry skin and mucous membranes,
Rationale > Helps differentiate individual disease and assesses severity of episode. >Avoiding intestinal irritants promotes intestinal rest.
Evaluation After 3 days of nursing intervention the goal was partially met. The patient’s watcher verbalized a mushy stool and less frequent of defecation.
> Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. > Indicates excessive fluid loss/resultant dehydration
> Monitor laboratory studies. anodyne suppositories > Electrolytes. decreased skin turgor. e.intestinal lumen. slowed capillary refill. .K-Lyte. COLLABORATIVE > Administer parenteral fluids. > Reduces fluid losses intestines. > Determines replacement needs and effectiveness of therapy.g. blood transfusions as indicated. from > Administer medications as indicated: Antidiarrheal e. > Electrolytes are lost in large amounts. electrolytes (especially potassium. especially in bowel with denuded.g. Slow-K). potassium supplement (KClIV. dipphenoxylate (Lomotil). ulcerated areas.. e. and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3). leading to secretory diarrhea.g. loperamide (Imodium). > Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. magnesium) and ABGs (acid-base balance). Note: fluids containing sodium may be restricted in presence of regional enteritis...
The statement supports the idea that the parents have deficient information regarding the illness of their child.Cues Subjective data: The mother stated that they don’t give any medication to their child. > Review disease process. and possible complicatio ns Review medications. Encourage questions. self-care. release of toxins that bind to specific enterocyte receptors release of Nursing Diagnosis Knowledge deficient regarding condition. purpose. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Goal/Plan After 8 hours of Nursing Interventi on the patient’s parent/ watcher will: >Verbalize understandi ng of disease processes. limang araw bago namin siya dinala sa ospital”. and discharge needs as related to unfamiliarity with resources and information misinterpretati on. treatment. fluids. the mother needs to be aware of what foods. Inference intestinal fluid output overwhelms the absorptive capacity of the GI tract damage to the villous brush border of the intestine. malabsorptio n of intestinal contents leading to an osmotic diarrhea. Although most others know about their own disease process. The patient’s watcher verbalized understand ing of disease processes. cause/effect relationship of factors that precipitate symptoms. Intervention/ Plan > Determine the mother’s perception of disease process. and lifestyle factors can precipitate symptoms. therefore. possible complication s. and identify ways to reduce contributing factors. Promotes understanding and > Evaluatio n After 3 days of nursing interventio n the goal was met. Rationale >Establishes knowledge base and provides some insight into individual learning needs >Precipitating/aggra vating factors are individual. prognosis. “akala ko normal lang namagtae siya. they may have outdated information or misconceptions. > .
proper handwashing techniques and perineal skin care.g. > .chloride ions into the intestinal lumen. leading to secretory diarrhea. > Emphasize need for longterm follow-up and periodic reevaluation. Stress importance of good skin care. and regular diagnostic evaluations may be required > . dosage. frequency. Patients with IBD are at risk for colon/rectal cancer.. e. infection. > may enhance cooperation with regimen Reduces spread of bacteria and risk of skin irritation/breakdown. and possible side effects.
r of blankets should alcohol. sunken mother. suggests nursing temperature 41.9Cpatient height 102F-106F gain or losedays days of of and weight in weight. of the manifested fontan malabsorption of by poor skin intestine. Note: Cases of fever free remittent from hypernatremic (varying only a few chills. as inadvertent tuberculosis (TB). > Obtain 24-hrinfections. of of temperature/numbe use Discourage infant’s energy needs.g.. . (+) sunken leading to an fontanel and fontanel release of toxins Wt.1C) nursing everyday and (degree and acute infectious interventio interventio compare it each pattern).8 osmotic kg(<2500 g) that bind to T-38. SGA specific release of enterocyte toxins that receptors bind to release of specific chloride ions into enterocyte the intestinal receptors lumen. secretory diarrhea. > commercial formulas. Intervention/Plan Rationale Intervention/P Rationale Evaluatio Evaluatio lan nn > Measure > Temperature baseAfter for initial data of > monitor > After 3 3 infant’s and to see (38. el Objective data: intestinal turgor. substitution ofbeand may cause altered to skim or whole deficiencies in iron. or appropriate. fontanels. turgor. reduced pneumococcalpoor skine for within her urine output pneumonia. The partially intake results in > Note status ofaid diaphoresis. and be free of chills. leading to hyperthermia . n n the goal the goal day. cultural/religious temperature spikes. infection. infection. period Factual or dietary suggests septic information may help inadequacies. suggest temperatur necessary fontanels. beliefs resulting or in endocarditis. IdentifyNote: Use of with brewer’s yeast adequate sourcesantipyretics alters milk of calcium and improves >Monitor production fever patterns and protein.24 hour by depressed diapers per day.1°C diarrhea. dehydration have degrees in either been associated with direction) use of cow’sreflects pulmonary milk feedings. production continuous and fever watcher did patient of number of wet more demonstrat diapers not fully mucus. skin turgor. with than simply adding maternal diet similar nutrients. note disease process. shaking Fever pattern fluid may was was met. may not meet the avoid mo. by(+) patient’s the brush border ion as intestine. or dietary recall inintermittent curves lactating mother.= 1. chloride ions into the Increase cellular intestinal metabolism lumen. > Illness.= 1. range and typhoid fever. and or mucous membranes. e. Increase cellular metabolism hyperthermia Cues Cues Inference Inference Goal/Plan After 3 3 After days ofdays of Nursing Intervention Nursing the patient Interventi will: the on patient’s parent/ watcher will: > Demonstrate temperature within normal range. for first Room sponge 12 life. . > Inadequate chills/profuse in diagnosis. > 102FSkim milk contains (38. suggest environmental significantly more may be restricted supplementing temperature.Nursing Nursing Diagnosis Diagnosis intestinal fluid intestinal Nutrition. turgor SGA leading to an (+)muscle contents sunken wasting osmotic diarrhea. limit/add yeast asuntil diagnosis is bed brewer’s linens as made or if fever appropriate. and curves lasting per manifested edgain weight number of wetthan day.8 malabsorptio muscle contents (+) poor skin kg(<2500 g) n of intestinal wasting. to nourish the infant 24-hour adequately. >Encourage about half the number > continued tepid of of calories in breast or Provide use formula baths. Hyperthermia Subjective data: fluid output output less than related to Objective overwhelms the dehydration overwhelms body data: “tapos ngayon absorptive the requirement as evidenced may lagnat siya capacity of the GI absorptive s related to by increase in (+) poor kaya pinupunasan capacity of tract excessive body skin ko siya para the GI tract turgor fluid loss temperature bumaba ang damage to the (+)muscle lagnat sabi ng damage to and higher than villous brush wastin doktor” verbalized border villous the of the g malsabsorpt normal range. teaching.or marginal diet may fever that returns affect mother’s ability Note presence ofto normal once in illness. Wt. dehydration. leading to secretory release of diarrhea. correct myths/ faulty septic Provide dietaryepisode. deliberate precede food Chills often noting restrictions. remains higher that indicated. sustained or patient’s The met. dryness of normal scarlet age.9C).. Supplementing diet practices.