DOÑA REMEDIOS T.

ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF NURSING
TACLOBAN CITY

NCM 103
FUNDAMENTALS OF NURSING
RLE WORKSHEET ON NURSING PROCESS
Name: Pagulayan, Marmiel M. Section: 1-C

Case Study

A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes
the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has
had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes
of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He
also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise
no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric
region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen.
Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes.

Formulate a Nursing Care Plan by using the format below.

Assessment Nursing Analysis Goal Intervention Rationale Evaluation
Diagnosis (with references) (Based on Nsg.prob.)
Subjective Diarrhea may Ascertain onset Short term: a. Independent Short term:
have been due and pattern of After 8 hours of 1. Observe and 1. Helps differentiate After 8 hours of
 He describes to placement of diarrhea, noting nursing interventions, document stool individual disease and nursing interventions,
ostomy in whether acute or the patient will be frequency, assesses severity of the patient was able
the quality of
descending or chronic. Acute able to: characteristics, episode. to:
the sigmoid colon, diarrhea (caused amount, and
abdominal Insufficient by viral, bacterial, 1. Reestablish and precipitating factors. 1. Reestablish and
pain as fiber or fluid or parasitic maintain normal maintain normal
sharp, intake, Stress, infections [e.g., pattern of bowel 2. Promote bedrest, 2. Rest decreases pattern of bowel
originating in anxiety Norwalk, functioning. if indicated, and intestinal motility and functioning.
the epigastric Rotavirus; provide bedside reduces the metabolic rate
Salmonella, 2. Verbalize commode. when infection or 2. Verbalize
region and
Shigella, Giardia; understanding of hemorrhage is a understanding of
radiating to amebiasis, complication. Urge to causative factors and
causative factors and
his back, and respectively]; rationale for defecate may occur rationale for
exacerbated bacterial treatment regimen. without warning and be treatment regimen.
by foodborne toxins uncontrollable,
movement. [e.g., 3. Demonstrate thus increasing risk of 3. Demonstrate
Staphylococcus appropriate behavior incontinence and falls if appropriate behavior
 He has had
aureus, to assist with facilities are to assist with
several Escherichia coli]; not close at hand.
resolution of resolution of
episodes of medications [e.g., causative factors causative factors (e.g.,
nonbloody, antibiotics, (e.g., proper food 3. Remove stool 3. Reduces noxious odors proper food
nonbilious chemotherapy preparation or promptly. Provide to avoid undue client preparation or
vomiting and agents, avoidance room deodorizers. embarrassment. avoidance
watery cholchicine, of irritating foods). of irritating foods).
diarrhea.
laxatives]; and 4. Discuss client’s 4. There is no one single
enteral tube usual diet. Have food or group of foods
 His mother Long Term:
feedings) lasts client/SO identify that precipitates
discloses that from a few days Long Term: problems for everyone
foods The patient was able
several up to a week. The patient will be and fluids (if any) with IBD. Dietary needs
Chronic diarrhea able to: and restrictions to:
family that precipitate
members at (caused by
 the time also irritable bowel 1. Maintain normal client’s diarrhea must be individualized, 1. Maintain normal
have syndrome, pattern of bowel and/or depending on which pattern of bowel
episodes of infectious diseases functioning. cramping pain. disease the client has and functioning.
affecting what part of the intestine
vomiting and
the colon [e.g., 2. The patient will is affected 2. The patient will
diarrhea. inflammatory (CCFA, 2013).
demonstrate demonstrate
 He admits to bowel disease], behavior/lifestyle behavior/lifestyle
decreased colon cancer changes to prevent 5. Restart oral fluid 5. Provides colon rest by changes to prevent
oral intake and treatments, complications intake gradually, if omitting or decreasing the complications
throughout severe client has been on stimulus of foods and
the duration constipation, bowel fluids. Gradual
malabsorption rest (NPO) during resumption of liquids
of his disorders, treatment. Offer may prevent cramping
symptoms. laxative abuse, clear liquids hourly and recurrence of
certain endocrine and avoid cold diarrhea; however, cold
Objective disorders [e.g., fluids. fluids can increase
(at least 3 each) hyperthyroidism, intestinal motility.
 Examination Addison’s
disease]) almost 6. Provide 6. Presence of disease
of the
always lasts opportunity to vent with unknown cause that
abdomen more than 3 frustrations related is difficult to cure
reveals weeks. to disease and that may require
tenderness in process. surgical intervention can
the epigastric Source: Nurse's lead to stress
region and Pocket reactions that may
the right Guide - aggravate condition.
Doenges,
lower Marilynn 7. Observe for fever, 7. May signify that toxic
quadrant on E. [SRG] tachycardia, megacolon or perforation
light to deep lethargy, and peritonitis are
palpation, leukocytosis, imminent or have
with decreased serum occurred, necessitating
radiation to protein, anxiety, and immediate medical
prostration. intervention.
his back on
palpation.
 No visible b. Independent and
marks or Collaborative
lesions on
1. Administer 1. 5-ASA agents work at
the abdomen.
medications, as the level of the lining of
 Complete indicated: the GI tract to decrease
blood cell Aminosalicylates (5- inflammation. They are
count, liver ASA), such as thought to be effective in
enzyme olsalazine treating mild-to-moderate
levels, (Dipentum) episodes of IBD, and are
and balsalazide useful in preventing
pancreatic
(Calazal), relapses of the disease.
enzyme sulfasalazine They work best in the
levels, and (Azulfidine), colon and are not
urinalysis mesalamine particularly effective if
results are all (Asacol), and the disease is limited to
within olsalazine the small intestine
normal (CCFA, 2013; Allen et al,
2011).
limits.
2. Steroids, such as 2. Long-term treatment
adrenocorticotropic with corticosteroids or
hormone (ACTH), use to maintain
hydrocortisone remission is undesirable,
(Cortenema, but may be given during
Cortifoam), acute flares (Allen et al,
prednisolone 2011). Steroids are
(Delta-Cortef), and contraindicated if
prednisone intra-abdominal abscesses
(Deltasone) are suspected.

3. Thiopurines, e.g., 3. May be given to block

azathioprine inflammatory response,
(Imuran), 6- decrease steroid
mercaptopurine
(6-MP, Purinethol), requirements, and
thioguanine promote healing of
(Tabloid) fistulas (Allen et al,
2011). Thiopurines have
not been shown to
increase risk of
death, as has been
associated with long-term
steroid use
(Lewis et al, 2009).

4. Biological 4. These drugs block

response modifiers tissue necrosis factor
(also called (TNF), a component of
immunomodulators), inflammatory response.
such as infliximab They help control
(Remicade), inflammation,
adalimumab trigger remission, and
(Humira), allow fistulas to close
certolizumab (Allen et al, 2011; Day,
(Cimzia), 2008).
natalizumab
5. Anti-infectives, 5. Used to treat bacterial
such as overgrowth in the small
metronidazole intestine caused
(Flagyl), by stricture, fistulas, or
ciprofloxacin prior surgery. May be
(Cipro), ampicillin, part of a longterm
and others treatment regimen (Allen
et al, 2011).

6. Prepare for 6. Two-thirds to three-

surgical quarters of patients with
intervention, such as Crohn’s disease will
colectomy, require surgery at some
point during their lives
proctocolectomy, or (Allen et al, 2011) if
ileostomy. perforation or bowel
obstruction occurs or
disease is unresponsive to
medical treatment.
Surgery (a colectomy)
can cure UC, and can
help, but not cure,
Crohn’s disease. Surgery
to remove the colon and
rectum (proctocolectomy)
isfollowed by ileostomy,
or ileoanal anastomosis.
If the client isn’t critically
ill and the anal sphincter
is free from lesions,
the surgeon may remove
the colon and rectum but
leave the anus intact. An
internal pouch is then
formed from the distal
ileum and connected to
the anal sphincter,
allowing the client
to have continent bowel
movements (Day, 2008).

Source: Murr, A.,

Doenges, M.,
Moorehouse, M. Nursing
Care Plans, 9th Edition
(2014)