NRLE FORM - 10

La Salle University
College of Nursing
Ozamiz City
NURSING CARE PLAN
ASSESSMENT NURSING DESIRED OUTCOME INTERVENTION with RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Diarrhea related to Within 8 hours of nursing Assessment: Assessment: Within 8 hours of nursing
gastrointestinal disorders as interventions, the patient will be interventions, the patient
“Ika 4 nako nalibang karung evidenced by frequency of stools able to: Independent: Independent: was able to:
adlawa ug akong tae kay basa (4x a day) and loose or liquid  verbalizes understanding of 1. Assess for abdominal 1. These assessment findings are  Verbalized
kaayonga nay dugo gamay” as stools. diarrhea’s causes and the discomfort, pain, cramping, usually linked with diarrhea. understanding of
verbalized by the patient. rationale for treatment. frequency, urgency, lose or Patients differ in their diarrhea’s causes and
 consume enough of clear liquid stools, and hyperactive definition of diarrhea, noting
the rationale for
liquids to maintain good skin bowel sensations. loose stool consistency,
increased frequency, the treatment.
turgor and normal weight.
Objective Data:  reestablishes and maintains a urgency of bowel movements,  consumed enough of
 BP: 170/100 normal pattern of bowel or incontinence as key clear liquids to maintain
 HR: 58 functioning. symptoms. good skin turgor and
 RR: 22 2. Everyone’s bowels are unique normal weight.
 Temp.: 36.5 to them. What’s normal for
 reestablished and
 02 Sat: 100% 2. Evaluate the pattern of one person may not be normal
defecation. for another. A person can maintained a normal
 Black tarry stool (+)
have a bowel movement pattern of bowel
anywhere from one to three functioning.
times a day at the most, or
three times a week at the
least, and still be considered
regular, as long as it’s their
usual pattern. Assessment of
defecation pattern will help
direct treatment.
3. Diarrhea can be caused by
certain medications such as
3. Review the medications the thyroid hormone replacement,
patient is or has been taking. stool softeners, laxatives,
prokinetic agents, antibiotics,
chemotherapy,
antiarrhythmics,
antihypertensives,
magnesium-based antacids.

Nursing Care Plan 2019

LA SALLE UNIVERSITY COLLEGE OF NURSING

4. Determine hydration status
by assessing input and
output.
5. Assess history for
gastrointestinal diseases.
6. Assess skin turgor.
7. Assess for other signs of
dehydration.
Collaborative:
1. Culture stool.
Nursing Care Plan 2019
LA SALLE UNIVERSITY COLLEGE OF NURSING
4. Diarrhea can lead to profound
dehydration. A prolonged
episode of diarrhea or
vomiting can push the body to
lose more fluid than it can
take in. The result is
dehydration, which happens
when the body doesn’t have
the fluid it requires to
function correctly.
5. Watery stools are
characteristic of disorders of
the small bowel, while loose,
semisolid stools are linked
more frequently with
disorders of the large bowel.
Voluminous, greasy stools
indicate intestinal
malabsorption, and the
presence of blood, mucus, and
pus in the stools indicates
inflammatory enteritis or
colitis.
6. A decrease in skin turgor is
exhibited when the skin (on
the back of the hand for an
adult or the abdomen for a
child) is pinched and released
but does not flatten back to
normal right away. Decreased
skin turgor and tenting of the
skin occur in dehydration.
7. Signs of dehydration include
thirst, urinating less
frequently than normal, dark-
colored urine, dry mouth and
tongue, feeling tired, sunken
eyes or cheeks,
lightheadedness or fainting,
and a decreased skin turgor.
Collaborative:
1. Testing or stool examinations
will distinguish infectious or
parasitic organisms, bacterial

Interventions:
Independent:
1. Weigh daily and note
decreased weight.
2. Have the patient keep a diary
of their bowel movements.
3. Explain the need to avoid
stimulants (e.g., caffeine,
carbonated beverages,
artificial sweeteners)
Nursing Care Plan 2019
LA SALLE UNIVERSITY COLLEGE OF NURSING
toxins, blood, fat, electrolytes,
white blood cells, and
potential etiological
organisms for diarrhea.
Interventions:
Independent:
1. Diarrhea causes severe water
loss from the body. As a
result, the body loses weight.
An accurate daily weight is an
important indicator of fluid
balance in the body.
2. Stool consistency needs to be
evaluated, which may be
accomplished by the patient
keeping a self-care log or
diary. Evaluation of
defecation pattern will help
direct treatment, especially
for cancer-related diarrhea.
Diary log should include the
time of day defecation occurs;
a usual stimulus for
defecation; consistency,
amount, and frequency of
stool; type of, amount of, and
time food consumed; fluid
intake; history of bowel habits
and laxative use; diet;
exercise patterns;
obstetrical/gynecological,
medical, and surgical
histories; medications;
alterations in perianal
sensations; and present bowel
regimen.
3. Caffeine may stimulate the
intestines and increase
motility. Aside from caffeine,
some sugary sodas also
contain high-fructose corn
syrup, a combination of
fructose and dextrose that
may lead to fructose

4. Record the number and
consistency of stools per day
5. Encourage intake of fluids
1.5 to 2 L/24 hr plus 200 mL
for each loose stool in adults
unless contraindicated;
consider nutritional support.
6. Encourage to take oral
rehydration solution.
7. Educate patient or caregiver
about dietary measures to
control diarrhea.
8. Remind the patient of the
importance of diet
Nursing Care Plan 2019
LA SALLE UNIVERSITY COLLEGE OF NURSING
malabsorption. Symptoms
include bloating and stomach
pain, heartburn, diarrhea, and
gas. Artificial sweeteners can
have a laxative effect. They
pull water into the colon and
aid to mobilize the stool,
which can cause the runs.
4. Documentation of output
provides a baseline and helps
direct replacement fluid
therapy. The Fecal Collection
System can also be used. It is
a closed catheter system used
in managing incontinence
patients with liquid or semi-
liquid stool.
5. It’s necessary to increase fluid
intake, especially when
experiencing diarrhea.
Increased fluid intake and
liquid meal replacements can
replenish fluid loss.
6. Drinking more water may not
be enough for a patient with
diarrhea. Aside from fluids,
the patient is also losing
important minerals and
electrolytes that water can’t
supply.
7. These measures include
avoiding spicy, fatty foods,
alcohol, and caffeine;
broiling, baking, or boiling
foods instead of frying in oil;
and avoiding disagreeable
foods. Specific foods and
diets are often incriminated as
causes of diarrhea, some with
good evidence and others less
so. These dietary changes can
slow the passage of stool
through the colon and reduce
or eliminate diarrhea.
 modification. 8. Diet modification is an
important part of self-
management for patients with
diarrhea. Advise patient to
look for foods with potassium
(such as potatoes, bananas,
and fruit juices), salt (such as
Dependent: pretzels and soup), and yogurt
1. Give antidiarrheal drugs as with active bacterial cultures.
ordered. Dependent:
1. Most antidiarrheal drugs
suppress gastrointestinal
motility, thus allowing for
more fluid absorption.
Supplements of beneficial
bacteria (“probiotics”) or
yogurt may reduce symptoms
2. Educate patient or caregiver by reestablishing normal flora
on the proper use of in the intestine.
antidiarrheal medications as 2. Antidiarrheal medications are
found in most drug stores or
ordered.
pharmacies, or a physician
can prescribe them. In taking
antidiarrheal medications,
discuss with the patient the
proper use of each
antidiarrheal medication to
prevent worsening of the
condition and prevent further
dehydration. Appropriate use
of antidiarrheal medications
can promote effective bowel
elimination.

Submitted by: Submitted to:

Name of Student: _Glacyl Joy D. Barola___________________________ _Miss Liezl B. Pagas___________________________

Year Level: _BSN-4________ Name of Clinical Instructor
Date: _January 20, 2023______ Date: _ January 20, 2023_______

Nursing Care Plan 2019

LA SALLE UNIVERSITY COLLEGE OF NURSING