ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Diarrhea related to After 3 days of 1. Observe and 1. Helps differentiate After 3 days of
presence of toxins as Nursing Intervention record stool individual disease nursing intervention
manifested by the patient’s parent/ frequency, and assesses severity the goal was partially
frequent elimination watcher will: characteristics, of episode. met. The patient’s
of mushy stools. amount, and watcher verbalized a
>Report reduction in precipitating factors. mushy stool and less
frequency of stools, frequent of
Objective Data: >return to more 2. Identify foods and 2. Avoiding intestinal defecation.
 Increased normal stool cons fluids that precipitate irritants promotes
bowel diarrhea, e.g., raw intestinal rest.
sounds/peristalsis vegetables and fruits,
 Frequent, and whole-grain cereals,
often severe, condiments,
mushy stools carbonated drinks,
 Changes in milk products
stool color
3. Monitor Intake and 3. Provides
Output. Note number, information about
character, and overall fluid balance,
amount of stools; renal function, and
estimate insensible bowel disease
fluid losses, e.g., control, as well as
diaphoresis. Measure guidelines for fluid
urine specific gravity; replacement.
observe for oliguria.

4. Observe for 4. Indicates excessive

excessively dry skin fluid loss/resultant
and mucous dehydration.
membranes,
decreased skin turgor,
slowed capillary
refill.
5. Monitor laboratory 5. Reduces fluid
 studies, e.g., losses from intestines
electrolytes
(especially
potassium,
magnesium) and
ABGs (acid-base
balance).