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Client Initials: Date: _ Course Student Source: _______

I. NANDA Nsg Dx.: Goal: Health/activity Interventions-Health/Activity Student Rationales Evaluation: Health Goal
Diarrhea (NOC-nrs outcome classifications NIC – nsg. intervention classification (Reason why intervention is appropriate or why (Corresponds w/Health Goal):
intervention helps patient accomplish outcome
planning stage) (positive statement of (What nrs does to assist client accomplish their Number to match each intervention)
Definition: problem): outcomes. Use action verbs. Address each goal &
Health Diagnostic: The client diarrhea has been
state who, what, when and how. Number each
one.): 1. s & s associated with diarrhea resolved
Passage of loose, unformed Patient has soft, brown, & formed 2. ↓ or absent bowel sounds may
stools no more than 3°daily Health Diagnostic:(Assess, Monitor):
stools 1. assess abdominal pain & cramping q indicate complication of treatment; Evaluation of Health
4 hrs constipation, toxic megacolon Outcomes (Be specific on how
Outcomes: Health/activity 2. assess bowel sounds q shift 3. monitors fluid volume status: client’s outcomes are met or not met.
(How the client’s health status changes or
3. assess hydration status: a) diarrhea can → profound Number to match “the client will”):
methods the pt uses to reverse, prevent or dehydration & electrolyte imbalance
control the defining char. Must be a) assess I&O’s q 2 hrs, ↓ frequency to 1. met – patient fluid intake = 2L+
no less then q shift as diarrhea b) ↓ skin turgor & tenting occur in daily
specific, measurable and have target
frequency↓ dehydration 2. partially met – patient’s had 1
II. R/T: Risk Factor date/time. Number each.): c) dehydration → dry mucous
b) skin turgor q shift BM on day 3; soft, brown, &
(Etiology/Possible Causes 1- 2): The client will: c) moisture of mucous membranes q membranes formed
Zosyn 2g IVPB shift 4. accurate assessment is vital in 3. Met – Potassium 4.3 day 2
1. drink a minimum of 2 liters of 4. assess pattern/frequency elim. q day making decisions about treatment & 4. Met –bowel sounds active x’s 4
fluid by day 2 5. assess perianal skin condition q bm follow up care by end of day 2
2. have soft, brown, formed stools ≤ 5. diarrhea stools → highly corrosive
III. Defining 6. monitor electrolyte levels as ordered
as result of ↑enzyme content
5. met - skin turgor had brisk return
3° daily by day 2 by day 3
Characteristics 3. have potassium WNL by day 2
Therapeutic:(Nrs. actions to comfort): 6. rehydration may → electrolyte,
1. offer fluid variety/choices qhr 6.Met – patient’s bottom dry &
AEB (as evidenced by): 4. have active bowel sounds x’s4 by osmolality, BUN, & Hct serum intact, no longer red & sore
day 2 2. Provide ready access to bedpan changes
3. admin. antidiarrheal meds prescribed
Subjective (what client says): 5. have brisk return of skin turgor
4. limit food intake, reintroducing solid Therapeutic:
“I have been on & off this bedpan by day 3 1. oral fluids encouraged as tolerated
6. have perianal skin intact, dry, & foods that have constipating effect Evaluation of Knowledge.
all morning” slowly & in small amounts; BRAT diet prevents dehydration
c/o abdominal cramping color appropriate for race 2. ↓ risk for soiling or injury; client Goal: (corresponds w/ Knowledge
5. assist in gentle perianal cleaning prn
sore bottom 6. apply protective ointment to perianal may have little warning of need to Goal):
area after q bm, prn defecate Met –
Goal: Knowledge 7. check for fecal impaction by digital 3. promotes comfort, prevents excess
Objective (S & S, supportive (Positive general statement of overall
examination q day fluid loss Evaluation of Knowledge.
client learning) use target dates 4. allows bowel to rest & mucosa to Outcomes: (Be specific on how
facts): Client will verbalize how to prevent Interventions:Teaching: heal in acute diarrhea states
Hyperactive bowel sounds client’s outcomes are met or not met.
spread of infectious diseases Diagnostic: (Assess needs and baseline 5. Cleansing removes irritating
Sluggish skin turgor Number to match “the client will”):
including those causing diarrhea knowledge): substances in stool.
6 loose stools today before discharge 1. –Assess readiness/willingness to learn 6.moisture barrier ointments/creams
Red bottom 1. Not met – patient not washing
ways to prevent spread of infectious protect the skin from excoriation &
Potassium is low ( 2.5) r/t hands after using restroom AEB
malabsorption Outcomes: Knowledge diseases help prevent tissue breakdown unused new hand soap in
(How client’s knowledge changes or 2. –Assess current knowledge about how 7. liquid stool may seep past impaction patient’s bathroom and not
methods pt will use to accomplish the infectious diseases can be spread, Teaching:
knowledge goal after nurse teaches) turning faucet on to wash hands
Therapeutic:(What nurse teaches) Diagnostic:
Spec. & measurable. Number each): 1. Teach client appropriate hand 1. Learning increases when ready and 2. Met – patient stated “I need to
The client will: washing technique ie.; 15 – 30 willing. wash my hands every time I use
1. demonstrate proper hand washing seconds minimum, paper towel to shut 2. Provides a baseline starting point. the bathroom, before preparing or
technique (washing hands without off faucet Therapeutic: eating any food, and after
prompting after using bathroom) 2. Teach client to utilize displayed hand 1. Hand washing is the best way to interacting with someone who is
2. verbalize 3 situations that merit sanitizer dispensers, & when she prevent spread of infectious diseases sick.” “I can use hand sanitizers
hand washing & a hand washing should wash her hands, ie; after using 2. see #1 when water & soap aren’t
alternative restroom, before preparing food or available.”
eating, before/after interacting with a
sick friend or family member.
Client Initials: Date: _ Course Student Source: _______
GRCC POC - 01-05-2010