NURSING CARE PLAN

DIARRHEA

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
OBJECTIVE DATA: IDENTIFIED: OBJECTIVES:  Promote bedrest  Rest OBJECTIVES:
and provide decreases
Vital Signs: Diarrhea After 8 hours of bedside intestinal Patient was able to
nursing care, commode. motility and re-establish and
BP: 165/95 mmHg patient will be reduces the maintain normal
Pulse Rate: 69 bpm able to re- metabolic bowel functioning.
NURSING
Respi. Rate: 15 cpm establish and rate when
DIAGNOSTIC
STATEMENT: maintain normal infection is a LONG TERM
 Patient’s history bowel complication. OBJECTIVES:
of portion of small functioning.  Restrict foods as  These foods
bowel resected 5 Diarrhea related The patient did not
indicated like can add more
years ago to gastro- foods containing irritation to experience an
(obstruction from intestinal LONG TERM caffeine , too the stomach episode of loose
scarring and inflammation as OBJECTIVES: much oil, fiber , stool
stricture) evidenced by milk and fruits
 Appendectomy at  
abdominal pain. After three days Observe and This will help
the age of 13 or until record stool differentiate
 Patient experience CAUSE ANALYSIS: discharged the frequency, individual
some mild fatigue patient will not characteristics, disease and
 Mild arteriolar In people with have an episode amount, and assesses
narrowing on Crohn’s Disease, of loose stool precipitating severity of
funduscopic exam the digestive tract factors. episode
without becomes inflamed  Restart oral fluid  This will
hemorrhages, even when there is intake gradually. provide colon
exudates, or not an infection. Offer clear rest by
papilledema The inflammation liquids hourly, omitting or
 Truncal obesity often leads to and avoid cold decreasing
with abdominal symptoms such as fluids. stimulus of
striae diarrhea. Diarrhea foods or
  Soft abdomen, not can be one of the fluids.
distended, and more unsettling Gradual
without bruits and brothersome consumption
 Guarding with symptoms of of liquids may
pressure to right Crohn’s Disease prevent
lower quadrant (Healthline.com) cramping and
 Hyperactive recurrence of
Bowel Sounds Damaged intestinal diarrhea. Cold
 No perineal wall tissue fluids can
lesions or Loss of ability to increase
absorb water intestinal
intestinal mass
More water to be motility.
 Stool is heme
excreted  Observe for the  This will help
negative diarrhea
• Up to 10 loose to semi- presence of to assess the
solid stools/day, non- associated causative
bloody factors and
factors such as
etiology.
abdominal pain,
bloody stools,
cramping or
emotional upset.
 Educate the  The anal area
patient about the should be
gently clean
perineal care
properly after
after each bowel a bowel
movement. movement to
prevent skin
irritation and
transmission
of
microorganis
m
 Identify foods  Avoiding
and fluids that intestinal
precipitate irritants
diarrhea promotes
intestinal rest
DEPENDENT:
 Take anti  Decrease GI
diarrheal motility or
medications as peristalsis
prescribed. and
diminishes
digestive
secretions to
relieve
cramping and
diarrhea.
These drugs
coat the
intestinal wall
and absorb
bacterial
toxins

COLLABORATIVE:  A culture is a
 Submit client’s test to detect
stool for culture. which
causative
organisms
cause an
infection.
 When a client
 Encourage experience a
patient to eat diarrhea, the
foods rich in stomach
potassium as contents
prescribed by the which is high
nutritionist in potassium
get flushed
out of the
gastrointesti-
 nal tract into
the stool and
out of the
body,
resulting in
hypokale-mia

ACUTE PAIN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE DATA: PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
IDENTIFIED: OBJECTIVES:  Provide measures  It is preferable to OBJECTIVES:
Vital Signs: to relieve pain provide an
Abdominal Pain At the end of 8 before it becomes analgesic before The patient
BP: 165/95 mmHg hours of duty, the severe the onset of pain verbalized
Pulse Rate: 69 bpm patient will or before it reduction of pain
Respi. Rate: 15 cpm NURSING verbalize becomes severe from a pain scale
DIAGNOSTIC reduction of pain when a larger of 4 in q 0-10
 Patient’s STATEMENT: from a pain scale dose may be scale with 10 as
history of of 4 in q 0-10 required the most painful
portion of Acute Pain scale with 10 as  Acknowledge and  Nurses have the
small bowel related to the most painful accept the client’s duty to ask their
resected 5 pain clients about their
years ago
inflammation
pain and believe LONG TERM
(obstruction Aeb guarding LONG TERM their reports of OBJECTIVES:
from scarring (behaviour?)not OBJECTIVES: pain. Challenging
and stricture) sure ani hehe or undermining The patient
 Appendecto ako ra gibutang After three days their pain reports demonstrated
my at the age butang or until discharge in an unhealthy ways to reduce
of 13 of the patient will therapeutic pain
 Patient demonstrate relationship
experience CAUSE ANALYSIS: ways to reduce  Determine and  Acute pain is that
some mild pain document which follows or
fatigue Intermittent, presence of occurs suddenly
 Mild partial small possible with onset of
arteriolar pathophysiological painful condition
 narrowing on bowel and psychological (Crohn’s Disease)
funduscopic obstruction in causes of pain (e.g
exam without inflammation or
Crohn’s Disease
hemorrhages, infections)
exudates, or can frequently
papilledema cause pain  Assess for referred  To help
 Truncal (Docherty, M. pain as determine
obesity with 2011) appropriate possibility of
abdominal underlying
striae Unregulated condition or
 (Soft inflammation organ dysfunction
abdomen, not Damaged requiring
distended, Gastrointestinal treatment
tissue
and without
Pain in affected area
bruits)-  Evaluate pain  Use pain rating
normal man characteristics and scale appropriate
basin ni ra intensity for age and
 Guarding cognition (0-10
with scale)
pressure to  Perform pain  This
right lower assessment each demonstrates
quadrant time pain occurs. improvement in
 Hyperactive Document and status or to
Bowel investigate identify
Sounds changes from worsening of
 No perineal previous reports underlying
lesions or and evaluate condition/develo
intestinal results of pain ping
mass intervention complications
 Appropriate  Provide comfort  To promote non
strength and measures and calm pharmacological
ROM activities pain management
 No femoral  Instruct and  To prevent
bruits encourage use of fatigue
relaxation
techniques
 Perform proper  Appropriate
nursing measures is best
 interventions and to prevent
appropriate complications
procedures to
alleviate pain

DEPENDENT:
 Take analgesics, as  To maintain
indicated, to “acceptable” level
maximum dosage of pain. Notify
as needed physician if
regimen is
inadequate to
meet pain control
goal.
Combinations of
medications may
be used on
prescribed
intervals
COLLABORATIVE:

 Evaluate  To check for any

laboratory results imbalances

DEFICIENT FLUID VOLUME

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
OBJECTIVE DATA: IDENTIFIED: OBJECTIVES:  Monitor and  These changes OBJECTIVES:
record vital signs in vital signs
Vital Signs: Dehydration After 8 hours of are associated .The patient was
nursing with fluid able to able to
BP: 165/95 mmHg interventions, volume loss exhibit moist
Pulse Rate: 69 bpm patient will:  Note the color. mucous membrane
NURSING
Respi. Rate: 15 cpm DIAGNOSTIC  able to May be dark and good skin
 STATEMENT: exhibit greenish turgor
moist  Observe or brown
 Warm and Deficient fluid mucous measure urinary because of LONG TERM
dry skin with volume related membrane output concentration OBJECTIVES:
flakiness and good  To avoid
to active fluid
 Poor skin skin turgor exhausting the The patient
turgor volume loss as patient, this maintained fluid
 Patient evidenced by may lead volume at a
experience poor skin turgor LONG TERM  Adequate rest more on fluid functional level
some mild and dry mucous OBJECTIVES: and sleep should loss demonstrate
fatigue be provided  To avoid other behaviors to
membrane monitor and
• Dry mucous After three days or fluid loses
membranes discharge, the through correct deficit, as
CAUSE ANALYSIS:
patient will: excessive indicated
Fluid Volume sweating
 maintain
deficit or fluid  Provide proper
hypovolemia volume at a ventilation and
occurs from a functional cool environment  To limit
loss of body fluid level gastric or
or the shift of demonstrat intestinal
fluids into the e behaviors  Provide frequent losses
to monitor oral as well as
third space, or and correct eye care
from a reduced deficit, as
fluid intake. indicated
Common
sources for fluid  Fluid loss
loss are the occurs first in
gastrointestinal extracellular
 Assess skin spaces,
(GI) tract. turgor, mucous resulting in
membrane every poor skin
Damaged intestinal
shift turgor and dry
wall tissue
mucous
Loss of ability to
membrane
absorb water
Active fluid volume
loss  To reduce
Prolonged diarrhea pressure on
dehydration fragile skin
DEPENDENT: and tissues
 To prevent
 Change position injury from
frequently dryness

 Take medications
(antidiarrheals)
as prescribe  This will be
used to
COLLABORATIVE: evaluate the
body’s
 Review response to
laboratory data fluid loss and
(e.g. to determine
haemoglobin, replacement
prothrombin needs.
time, activated
partial
thrompoblastin
time, electrolytes
(sodium,  To deliver
potassium, fluids
chloride, accurately at
bicarbonate) desired rates
 IVF administered
as ordered.
Maintained at
proper regulation