NURSING CARE PLAN

Select the top priority nursing diagnosis and complete this nursing care plan.
ERICA SCHLOSSER CLIENT INTITIALS: GM DATE 2/14/2013
I. NURSING DIAGNOSIS III. CLIENT DAY OF CARE OUTCOMES (2 to 3)
Diarrhea r/t adverse effect of medications(Protonix), and surgical
procedure. A. Patient will state relief from cramping and less or no
diarrhea.
II. DISCHARGE OUTCOME(S))

a
Patient will state relief from cramping and less or no diarrhea by B. Patient will maintain weight as usual level.

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discharge.
Patient will defecate formed, soft stool everyday to every third day by C. Patient will maintain adequate nutrition, to prevent
discharge. malnutrition.

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IV. NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
 Inspect, auscultate, palpate, and percuss  “Expect increased frequency of Day of Care Outcome(s)

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the abdomen in that order. bowel sounds with diarrhea.” Met Unmet Partially Met
Documentation: (State behaviors that patient exhibited
 Assess for dehydration by observing skin (Bickley & Szilagyi, 2009) pg 324

turgor over sternum and inspecting for
longitudinal furrows of the tongue. Watch
for excessive thirst, fever, dizziness,
 “Severe diarrhea can cause deficient
fluid volume with extreme
weakness.” (Mentes, 2006) “Acutely
sh
that helped you determine that day of care outcome(s)
were met. Also discuss interventions implemented to
reach day of care outcome(s).
Patient had no complaints of diarrhea by the end of the shift.

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lightheadedness, palpitations, excessive ill clients are at risk for Patient is maintaining adequate nutrition, and is maintaining
cramping, bloody stools, hypotension, and hemodynamic and metabolic weight.

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symptoms of shock. instability because of fluid and
 Weigh the client daily and note decreased electrolyte imbalances caused by
weight. diarrhea.” (Thorson, Bliss, & Savik,

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 Encourage the client to eat small, frequent
meals, to consume foods that are easy to
digest (bananas, crackers, pretzels, rice,
co rc  “An accurate daily weight is an
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potatoes, clear soups, applesauce), and
to avoid milk products, foods high in fiber,
and caffeine (dark sodas, tea, coffee,
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chocolate).
 Teach signs and symptoms of dehydration
and electrolyte imbalance.
se dy
2008) pg 325
important indicator of fluid balance
in the body.” pg 325
Discharge outcome(s)
Met Unmet Partially Met
Documentation: (State behaviors that patient exhibited
 “The BRAT diet has been traditionally that helped you determine that discharge outcome(s) met.
Also discuss interventions implemented to reach
recommended but if used, should
discharge outcome(s).
be used for only short periods of WAS NOT THERE WHEN PATIENT WAS DISCHARGED
time as it is nutritionally incomplete.” FROM HOSPITAL, MAKING ME UNAWARE OF RESULTS.
(Centers of Disease Control and RESULTS UNKNOWN.
Prevention, 2003) pg 325

 pg 327
Plan Updates: (Include new interventions, change in
outcomes, deletions of outcomes, interventions,
continuations of interventions)
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All interventions/rationale from Nursing

Diagnosis Handbook. Ackley, Ladwig. Pgs
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323-328
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