DIARRHEA

PATIENT ASSESMENT

BIBLIOGRAPHY

Campbell, cline . 1989. Nursing diagnosis Dan intervention in nursing

practice second edition. Canada: A Wiley medical publication.

Doenges, Marilynn E. 1989. Nursing care plans edition 3.

United stated of America: F.A. Davis company.

Thompson, June M. 1986. Clinical nursing 3. United states of America

the C. V; Mosby company.

 DIARRHEA

ASSESMENT
A. Patient Identity
1. Name
2. Gender
3. Age
4. Work/Job
5. Education
6. Marietal Status
7. Nationality
8. Assurance
9. Address
10. Hospital Register Number
11. Data of Entering
B. Nursing Care Plans
1. Main sigh
Client come with defecate sigh. Defecate more than 3 times, vomit
passion eat downhill, sometimes the body of temperature high.
Generally feces form of dilution can mixed mucus, blood.
2. Present disease history
a. When the client experience of sigh
b. What the caused of diarrhea?
c. What had been to overcome the sigh?
d. What the client had been decrease lust to eat, vomit and
stomachache
3. Last disease history
a. What the client have suffered disease of from same previous?
b. What the client have suffered disease that ataek gastrointestinal
channel like dysentri or cholera?
4. History of family disesase
a. Do your family have a same disease like you?
5. Phisically assesment
a. General situation
Weakness, fatique, malaise.
b. Vital sign
 Temperature : 380C
 Blood pressure : 90/60 mm Hg
  Breathe : 25 x/Minutes
 Heart rate : 95 x/Minutes
c. Eye
Eye paint,mucous membrane pale, blurred vision.

d. Skin
Skin/mucous membranes : poor turgor ;dry, skin lesions may be
present; e.g. erythematic nod sum (raised, tender, red and swollen)
on arms, face; pyoderma gangrenousum (purulent pinpoint
lesion/boil with a purple border) on trunk, legs, ankles.
e. Mouth
Cracking of tongue (dehydration/malnutrition).
f. Abdomen
Abdominal tenderness/distention, diminished bowel sound, absence
of peristaltic or presence of visible peristaltic
g. Activity/rest
Weakness, fatigue, malaise, exhaustion, insomnia, not sleeping
through the night because of diarrhea. Feeling rest less and
anxious. Restriction of activities/work due to effects of disease
process
h. Circulation
Tachycardia (response to fever, dehydration, inflammatory process,
and pain). Bruising, ecchymotic areas(insufficient vitamin k).
Bp : hypotension, including postural.
i. Ego integrity
Anxiety, apprehension, emotional, upsets, e g: feelings of
helplessness/hopelessness.
Acute/chronic stress factors , e. g , .family/job – related, expense of
treatment.
Cultural factor – increased prevalence in Jewish population.
Withdrawal, narrowed focus, depression.
j. Elimination
Stool texture varying from soft formed to mushy or watery
unpredictable, intermittent, frequent. Uncontrollable episodes of
bloody diarrhea. (as many as 20 - 30 stools/d): sense of urgency/
cramping (tenesmus); passing blood/pus/mucus with or without
passing feces. rectal bleeding. History of renal stones(dehydration).
Diminished bowel sounds, absence of peristaltic or presence of
visible peristaltic hemorrhoid, anal fissures (25%); perianal fistula
(more frequently with crohn,s) oliguria.
k. Food/fluid
Anorexia : nausea/vomiting
Weight loss
Dietary intolerance /sensitivities, e.g. , raw fruits/vegetable, dairy
products fatty foods
 Decreased subcutaneous fat/muscle mass
Weakness, poor muscle tone and skin turgor
Mucous membrane pale; sore, inflamed buccle cavity.

l. Hygiene
Inability to maintain self-care
Stomatisis reflecting vitamin deficiency
Body odor
m. Pain/comfort
Paint/tenderness in lower – left quadrant (may be relieved with
defecation)
Migratory join pain, tenderness (arthritis)
Eye pain, photophobia
Abdominal tenderness/distention.
n. Safety
History of lupus erythematosus, hemolytic anemia, vasculitis
Arthritis (worsening of symptoms with exacerbations in bowel
disease)
Temperature elevation 104 – 1050F(acute exacerbation)
Blurred vision
Allergies to food/milk products(release of histamine into bowel has
an inflammatory effect)
Skin lesions may be present; e.g., erythematic nod sum (raised
tender, red and swollen) on arms, face; pyoderma gangrenous
(purulent pinpoint lesion boil with a purple border) on trunk, legs,
ankles.
Ankylosing spondylitis
Uveitis, conjunctivitis/iritis.
o. Sexuality
Reduced frequency/avoidance of sexual activity
p. Social interaction
Relationship/role problems related to condition inability to active
socially

NURSING DIAGNOSIS
a. Diarrhea may be related to presence of toxins
Actions/ Interventions Rationale
 Observe and record stool  Helps diferentiate individual
frequency, characteristics, disease and assesses severity of
amount, and precipitating episode.
factors.

 Promote bedrest, provide  Rest decreases intestinal motility

bedside commode. as well as reducting the
metabolic rate when infection or
 hemorrhage. is complication.
Defecation urges may occur
without warning and be
uncontrollable, increasing risk of
incontinence/falls if facilities are
not close at hand.

 Remove stoo promptly.  Reduces noxious odors to avoid

Provideroom deodorizers. undue patient embarrassment.

 Provide opportunity to  Presence of disease with

ventrutions related to disease unknown cause that is difficult to
process cure and that may reguire
surgical intervention can lead to
stress reactions that may
aggravate condition.

b. Fluid volum deficit risk factors may include excessive losses through
normal routes (severe frequent diarrhea, vomiting).

Actions/ Interventions Rational

 Monitor 1 & 0, not number,  Provides information about
character,and amount of stool; overall fluid balance, renal
estimate insensible fluid losses; function, and bowel.disease
e.g., diaphoresis. Measure urine control, as well as guidelines for
specific gravity, observe for fluid replacement.
oliguria

 Asses vital signs(bp, pulse,  Hypotension (including postural),

temperature). tachycardia, fever can indicate
response to and /or effect of fluid
loss.

 Weigh daily  Indicator of overall fluid and

nutritional status.

 Observe for overt bleeding and  Inadequate diet and decreased

test stool daily for occult blood. absorption may lead to vitamin K
deficiency and defects in
coagulation, potentiating risk of
hemorrhage.

 Note generalized muscle  Excessive intestinal loos may

weakness or cardiac lead to electrolyte imbalance,
dysrhythmias. e.g., potassium, which in
 necessary for proper skeletal and
cardiac muscle function. Minor
alterations in sorum levels can
result in profound and/or life-
threatening symptoms

c. Nutrition, altered: less than body reguirements may be related to altered

absorption of nutrients.

Actions/ Intervention Rationale

 Weigh daily  Provides information about
dietary needs/effectiveness of
therapy

 Recommend rest before  Quiets pristalsis and increases

meals available energy for eating

.
 Provide oral hygiene  A clean mouth can enhance
the taste of food.

 Encourage patient to  Hesitation to eat may be

verbalize feelings concerning result of fear that food will
resumption of diet cause exacerbation of
symptoms

d. Pain (acute) may be related to hyperperistalsis, prolonged diarrhea,

skin/tissue irritation perirectal excoriation, fissures; fistulas.

Actions/ Intervention Rationale

 Encourage patient to report pain  May try to tolerate pain, rather
than request analgesics.

 Note nonverbal clues, e.g.  Body language/nonverbal clues

restlessness, reluttance, may be both physiologic and
abdominal guarding, withdrawel, may be used in conjunction with
and depression. Investigate verbal es to edentity
discrepancies between verbal extent/severity of the problem
and nonverbal clues.

 Review factors that aggravate or  May pinpoint precipitaling or

alleviate pain. aggravating factors (such as
stressfull events, food
intolerance) or identify
 developing complications.

 Observe/record abdominal  May indicate diveloping

distention, increased temperature intestinal obstruction from
decreased BP. inflammation, edema, and
scarring.