NURSING CARE PLAN BY SANTOS, EMMA LYN S.
BSN 1-D
ASSESSMENT
Subjective:
- "mainit ang pakiramdam ko" as
verbalized by the patient
- expressed body weakness and
watery stool, a day prior to
consultation.
Objective:
- Initial vital signs are taken as
follows:
--> TEMPERATURE : 39.1 degree
celcius
--> PULSE RATE: 88bpm
--> RESPIRATORY RATE: 24
breaths per minute
--> BLOOD PRESSURE: 110/80
mmHg
NURSING DIAGNOSIS PLANNING
Diarrhea related to watery Short Term:
stools, hot flushes and body
weakness. -After 1 hour of appropriate
nursing intervention, the patient's
Associated factor: Fever temperature will decrease to 38
with increased respiratory degrees celcius.
rate. - After 5-8 hours of appropriate
nursing intervention, the patient
will re-establish and maintain
normal bowel functioning.
Long Term:
- After 4-8 hours of appropriate
nursing intervention, the patient's
vital signs will return to normal
range; with a temperature of
36.5-37.5 deg. celcius and
respiratory rate of 12-20 breaths
per minute.
- After 1-2 days of appropriate
nursing intervention, the patient
will be free of diarrhea.
INTERVENTIONS
Independent:
1. Ascertain onset and
pattern of diarrhea,
noting whether acute or
chronic.
2. Evaluate diet history,
noting food allergies or
intolerances and food
and water safety issues,
and note general
nutritional intake and
fluid and electrolyte
status.
3. Monitor vital signs.
4.. Provide tepid sponge
bath.
5. Promote a well
ventilated area for the
patient.
6. Maintain bed rest.
7. Note reports of
abdominal or rectal pain
associated with episodes.
8. Advise patient to have
an increased fluid intake
and avoid cold fluids and
foods that are oily, spicy
and reduce caffeine
intake.
9. Advise patient to
decrease solid food
intake and eat foods like
apple and banana.
10. Observe and record
stool frequency,
characteristics, amount
and other factors.
11. Recommend
change in drug
therapy, as appropriate
Dependent:
1. Administer
paracetamol, anti
diarrheal agents/
antibiotics as prescribed
characteristics, amount
and other factors.
11. Recommend
change in drug
therapy, as appropriate
Dependent:
1. Administer
paracetamol, anti
diarrheal agents/
antibiotics as prescribed
by the physician.

2. Administer enteral
and parenteral fluids,
as indicated.
MMA LYN S.

RATIONALE EVALUATION

- Acute diarrhea (caused

- After 8 hours of nursing care, the
by viral, bacterial, or patient's temperature lowered down
parasitic infections. to 37 degree celcius and a respiratory
Chronic diarrhea caused by rate of 18 breaths per minute. Pulse
irritable bowel syndrome, rate and blood pressure is also
infectious diseases maintained normal.
affecting the colon.
- After 2 days of nursing care, the
- To know if the patient has patient reports hardened stools, no
allergies or intolerances in signs of hot flushes and a normal
food and fluid intake. body functioning such as normal
bowel movement and re established
normal body strength.
- Vital signs provide more
accurate indication of core
temp.
- Tepid sponge bath lowers
body temperature.
- To decrease warmth and
increase evaporative
cooling.
- To promote clear flow of
air in the patient's area and
promote heat loss.
- Pain is often present with
inflammatory bowel
disease, irritable bowel
syndrome, and mesenteric
ischemia.
- Foods that are stool
former. Also, to avoid
foods or substances that
precipitate diarrhea.
- To allow for bowel rest and
reduced intestinal workload.

- Helps differentiate
individual disease and assess
severity of episode.
former. Also, to avoid
foods or substances that
precipitate diarrhea.
- To allow for bowel rest and
reduced intestinal workload.

- Helps differentiate
individual disease and assess
severity of episode.

- If the drug theraphy is not

effective for the patient.

- To decrease
gastrointestinal motility
and minimize fluid losses.