Nursing Care Plan
Nursing Problems / Cues Analysis & Health Implication Nursing Interventions
Goal and Objectives
Rationale
Evaluation
1. Loose watery stool related to Inflammation of the Gastro- intestinal tract (AGE) Subjective: The client sought to consult his chief complaint of loose watery stool with an admitting diagnosis of Acute Gastroenteritis. Then he was subsequently admitted. According to the client, the history of present illness started few hours prior to admission
Definition: Passage of loose, unformed stool. Health Implication: Acute Gastroenteritis is an inflammation on the stomach & GI tract which is manifested by diarrhea, abdominal pain associated with nausea, vomiting, fever, and abdominal distention& excessive elimination of waste caused electrolyte imbalance
Goal: After the shift, the client will be able to reestablish and maintain normal pattern of bowel functioning. Objectives: After 8 hours of nursing intervention, the client will be able: 1. To eliminate causative factors. Restrict solid foods. To allow for bowel rest and reduced To avoid foods or substances that precipitate diarrhea To avoid foods or
Provide for changes in dietary intake
Limit caffeine, and
Goal: The goal was met. After the shift, the client was able to reestablish and maintain normal pattern of bowel functioning as manifested by the following: Verbalization of clients relief from crampy abdominal pain Defecated semisolid stool at least twice a day No distress noted With good appetite already Abdomen is symmetrical, soft, globular and without distention
(May 9, 2009) as 11 episodes of passage of watery, foul smelling, non-blood stained stools amounting to cup per bout. Moreover, he has preference for raw foods. In fact, he had eaten raw oyster last week and he thinks that this was the cause of his loose watery stool. Kumain ako ng talaba noong isang linggo, siguro eto yung naging dahilan ng pagsakit ng tiyan ko, as added by Mr. X. Pero ayos na ang tiyan ko di na ganun kasakit tulad ng dati, as verbalized by the client. Siguro kung sa 110, siguro mga 5 or 6 kasi medyo may sakit pa din. Parang may hangin, as
(Reference: Medical Surgical Nursing 10th Ed by Brunners & Suddarth) Abnormal loss of intestinal fluid occurs in the presence of diarrhea, Imbalances likely to occur in these situations are: - Fluid Volume Deficit - Metabolic Acidosis - Sodium DeficitPotassium Deficit
high-fiber foods; avoid milk and fruits as appropriate. Assist in treatment of underlying conditions and complications of diarrhea.
substances that precipitate diarrhea
Therapies can include treatment of fever, pain, and infectious and toxic agents; rehydration; oral refeeding.
(-) tenderness in epigastric area Decreased hyperactive bowel sounds Effectiveness: With the interventions done, the client was able to eliminate causative factors prior to the problem. The client was able to maintain hydration and electrolyte balance. Appropriateness: The interventions were appropriate for clients condition and age.
Promote use of relaxation techniques. (e.g. sleeping, playing, listening to music, watching television shows) Assess for presence of postural hypotension, tachycardia, skin hydration/turgor, and condition of mucous membranes. Get the input and output of the patient
To decrease stress/anxiety
(Reference: Nurses Handbook of Fluid Balance, 4th edition by Metheny Snively, p. 221)
It indicates dehydration.
2. To maintain hydration and electrolyte balance
Acceptability: The interventions were acceptable and suitable to clients belief and practices. Adequacy: The resources and interventions were adequate. Efficiency:
To determine amount of output and fluid replacement needs.
verbalized by the client. During our interview, the client defecates for 3 times already. The consistency of the stool is soft to liquid consistency.
Administer antidiarrheal medications, as indicated. (Nifuroxazide 1 cap prn for every bout of loose stool) Encourage oral intake of fluids containing electrolytes, such as juices, bouillon, or commercial preparations, as appropriate. Administer enteral and IV fluids as indicated. (Plain NSS 1 liter x 100cc/hr) Increase oral fluid intake and return to normal diet, as tolerated. 3. To promote return to normal bowel Administer
To decrease gastrointestinal motility and minimize fluid losses.
The interventions done were within the time frame and the time materials and human resources were used economically.
Objective: (+) distress noted Looks unhealthy with obvious illness (+) weakness (+) loss of appetite Abdomen is symmetrical, soft and globular With distended abdomen (+) tenderness in epigastric area (+) hyperactive bowel sounds
To maintain electrolyte balance and to replenish the loss of fluids and electrolytes.
To maintain hydration and electrolyte balance.
To maintain electrolyte balance and to replenish the loss of fluids and electrolytes. To treat infectious process, decrease
functioning
medications, as ordered. (Antibiotic: Metronidazole 500 mg/tab, 1 tab every 6 hours)
motility, or absorb water.
