Planning

Nursing
Assessment Implementation Evaluation
Diagnosis Objective of Care Intervention Rationale

Diarrhea Subjective After 3 hours of  Ascertain Data required as Established After 3 hours of
related to Cues: nursing usual baseline for future patient’s usual nursing
intervention, the elimination evaluation of elimination intervention, the
Inflammation, “Naga-LBM therapeutic needs client was able
client will be able habits. habits.
Irritation, ako. Yung and effectiveness. to:
to:
tae ko is basa
Intestinal
at parang 1. Maintain usual 1. Maintain
Malabsorption bowel Assessed normal
may konting Defines
 Assess bowel patient’s bowel
or Partial dugo.” As consistency/ problem (diarrhea, bowel
sounds and sounds and
verbalized by pattern. constipation). Note: consistency/
Narrowing of record bowel record bowel
the patient. Constipation is one pattern.
the Intestinal movements movements.
2. Verbalize of the earliest
(BMs)
Lumen, Objective understanding manifestations of 2. Verbalize
including
Cues: of factors and neurotoxicity. under-
Secondary to frequency,
appropriate Monitored standing of
Passed loose consistency
the Process of interventions/ factors and
(particularly patient’s I&O
Intestinal
watery stools solutions appropriate
during first and weight.
for 5 times related to intervention/
Malignancy 3–5 days of
already. individual solutions
Vinca
situation. related to
Presence of alkaloid
individual
abdominal therapy).
situation.
cramps Encouraged the
patient to
 Monitor I&O Dehydration,
increase fluid
and weight. weight loss, and
intake.
electrolyte
imbalance are
complications of
diarrhea.
Inadequate fluid
intake may Provided patient
potentiate with appropriate
constipation. meals and
adjusted their
diet as
 Encourage May reduce appropriate.
adequate potential for
fluid intake constipation by
(2000 mL per improving stool
24 hr), consistency and
Checked patient
increased stimulating
for impaction.
fiber in diet; peristalsis; can
regular prevent dehydration
Monitored
exercise. associated with
patient’s
diarrhea.
 laboratory
studies.

Reduces gastric
 Provide irritation. Use of
small, low-fiber foods can
frequent decrease irritability
meals of and provide bowel
foods low in rest when diarrhea
residue (if not present.
contraindicat
ed),
maintaining
needed
protein and
carbohydrates
(eggs.,
cooked
cereal, bland
cooked
vegetables).
GI stimulants that
may increase
 Adjust diet as gastric motility
appropriate: frequency of stools.
avoid foods
high in fat
(butter, fried
foods, nuts);
foods with
high-fiber
content; those
known to
cause
diarrhea or
gas (cabbage,
baked beans,
chili); food
and fluids
high in
caffeine; or
extremely hot
or cold food
and fluids.

Further
interventions and
 Check for alternative bowel
 impaction if care may be
patient has needed.
not had BM
in 3 days or if
abdominal
distension,
cramping,
headache is
present.

 Monitor
laboratory
studies as
indicated: Electrolyte
imbalances may
 Electrolytes contribute to
altered GI function.

Prevents
dehydration, dilutes
 Administer chemotherapy
IV fluids as agents to diminish
indicated side effects.

May be indicated to
control severe
 Anti- diarrhea.
diarrheal
agents as
indicated
DATE/TIME FOCUS DAR
December 14, 2020
7:00am – 3:00pm Diarrhea related to Fluid
Volume Decrease
Received patient on bed
7:00 am awake

D – “Naga-LBM ako. Yung

tae ko is basa at parang may
7:30 am konting dugo.” As verbalized
by the patient.

Signature:
8:00 am
A–
Monitor vital signs

Signature:

Monitor the bowel

movements and its quality,
9:00 am quantity, color, consistency,
amount, shape, odor, and the
presence of mucus of the
patient.

Signature:
2:00 pm

Check for signs of

dehydration such as dry
mouth, lethargy, weakness in
muscles, headache and
dizziness.

Signature:

Administer IV fluids as
indicated

Signature:

3:00 pm
Increase patient’s fluid intake

Signature:

Encourage patient to eat

small, frequent meals and to
consume foods that are easy
to digest.

Signature:

Restrict foods as indicated

like foods containing
caffeine, too much oil, fiber,
milk, and fruits.

Signature:

R – Patient verbalized “Hindi

na ako masyado naga-tae,
mga once or twice nalang.
Hindi na dn masakit mag-
tae.”

Signature:

Nurse on Duty:
Fatima Medriza Duran
Signature:

Clinical Instructor:
Marites A. Yusop
Signature:

Student Nurse:
Danielle D.T. Arca
Signature: