NURSING CARE PLAN

NURSING DIAGNOSIS

• Acute abdominal pain related to severe diarrhea

ASSESSMENT

Subjective cues:• “Masakit ung tiyan ko parati pag dumudumi ako” as

verbalized by the patient. (indicating whole abdomen)

Objective cues:• Pain scale of 4/10• Guarding behaviour • Facial mask of pain• Expressive behaviour( restlessness, sighing)

ANALYSIS

• Abdominal pain is a very common symptom, and also common in children. Unfortunately, many cases of acute appendicitis are misdiagnosed each year as gastroenteritis or some other condition, especially in children and infants.

• Abdominal pain is common and often inconsequential. Acute and severe abdominal pain, however, is almost always a symptom of intra-abdominal disease.

Goals and Objectives Intervention Rationale Evaluation

Goal: After 30 mins nursing intervention the client’s pain will be relieved as evidenced by a pain scale of 2/10

Objectives: Independent:

After 30 mins nursing intervention the patient’s pain was relieved as evidenced by a pain scale of 2/10

1. After 5 mins of nursing intervention, the patient will be able to describe the pain she experiences.

Note reports ofpain, including location, duration, intensity(1-10

Pain is not always present, but if the present should be compared with the client’s previous pain symptoms. This comparison may assist in diagnosis of etiology of bleeding and development of complications.

The patient was able to describe the pain she experiences.

Goals and Objectives Intervention Rationale Evaluation

Review factors that aggravate or alleviate pain.

Helpful in establishing diagnosis and treatment needs.

Note nonverbal pain cues

Nonverbal cues may be both physiologic and psychologic and maybe used in conjunction with verbal cues to evaluate extent/severity of the problem.

Goals and Objectives Intervention Rationale Evaluation

2. After 15 mins of nursing intervention, the patient will be able to state 3 out of 5 pain management techniques.

Discussion of pain management techniques

It will facilitate patient’s independence in making choices on how to manage her condition

The patient was able to state 3 out of 5 pain management techniques.

Identify and limit foods that create discomfort

Specific foods that cause distress vary among individuals.

Goals and Objectives Intervention Rationale Evaluation

Respond immediately to complaint of pain

Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship.

Eliminate additional stressors or sources of discomfort whenever possible.

Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.

Goals and Objectives Intervention Rationale Evaluation

Provide rest periods to facilitate comfort, sleep, and relaxation.

Pain may result in fatigue, which may result in exaggerated pain and exhaustion.

3. After 10 mins of nursing intervention, the patient will be able to state in her own words the importance of adhering to prescribed therapy and medications.

Discussion of medications.

Knowledge about medications will increase client’s compliance and independence.

The patient was able to state in her own words the importance of adhering to prescribed therapy and medications.

Goals and Objectives Intervention Rationale Evaluation

Provide and implement prescribed dietary modifications

Dairy products are contraindicated because it can increase gastric acid production

Administer medications , as indicated;Anticholinergic Proton-pump inhibitor

Decrease spasmodic events

Decrease pathologic hypersecretion

NURSING CARE PLAN

NURSING DIAGNOSIS

• Risk for deficient fluid volume related to

prolonged diarrhea.

ASSESSMENTSubjective cues:• “Dumi ako ng dumi tapos matubig pa yung inilalabas ko” as verbalized by the patient. • “Madaming beses sa isang araw kung pumunta ako sa banyo”, as verbalized by the patient. • “Talagang tubig yung dinudumi ko tapos minsan may buo naman pero matubig pa din halos”, as

verbalized by the patient. Objective cues:• Dry mucous membrane• Increased body temperature• Weakness• Elevated white blood cell count• Increased Hematocrit concentration• + 6 loose stools a day, watery in form

ANALYSIS• Acute diarrhea or gastroenteritis is the passage of loose stools

more frequently than what is normal for that individual. This increased frequency is often associated with stools that are watery or semisolid, abdominal cramps and bloating.

Acute watery diarrhea is an extremely common problem, and can be fatal due to severe dehydration, in both adults and children, especially in the very young and the old or in those who have poor immunity such as individuals with HIV infection or patients who are using certain medications that suppress the immune system.

• As a result of the fluid loss, the patient will demonstrate signs of dehydration, such as dry skin, poor skin turgor, dry mucous membranes, thirst, weakness, headache, tachycardia, othostatic hypotension, and decreased blood pressure.

Goals and Objectives Intervention Rationale Evaluation

Goal: After 2 hours of appropriate nursing intervention the patient will demonstrates adequate fluid balance as evidenced by stable vital signs, moist mucuos membranes and decreased diarrhea.

Objectives: Independent:

After 2 hours of nursing intervention the patient demonstrated adequate fluid balance as evidenced by stable vital signs and decreased diarrhea.

1. After 10 mins of nursing intervention, the patient will be able to state in her own words the importance of maintaining adequate fluid volume in the body.

Discussion of the importance of maintaining adequate fluid volume.

Acquiring adequate knowledge about the condition will facilitate patient’s compliance.

The patient was able to state in her own words the importance of maintaining adequate fluid volume in the body.

Goals and Objectives Intervention Rationale Evaluation

Assess causative/ precipitating factors

To be able to plan nursing action

Monitor colour and consistency of stool; encourage patient to describe unwitnessed passing of stool using common household measures (e.g a cupful, spoonful)

Careful assessment of GI bleeding can help determine the exact site of the bleeding.

Goals and Objectives Intervention Rationale Evaluation

2. After 10 mins of nursing intervention, the patient will be able to state 3 out of 5 complications of fluid imbalance (focusing on fluid deficit).

Discussion of the complications of fluid imbalance

Knowledge about possible complications may increase compliance to therapy

The patient was able to state 3 out of 5 complications of fluid imbalance (focusing on fluid deficit).

Monitor for signs/symptoms of increased/ continued diarrhea and weakness.

Prolonged diarrhea and restricted oral intake can lead to deficits in sodium, potassium and chloride.

Goals and Objectives Intervention Rationale Evaluation

Determine effects of age

lderly individuals are at higher risk because of decreasing effectiveness of compensatory mechanism

Maintain accurate record of I&O, noting output less than intake and assess skin/ mucuos membranes.

Provides information about fluid status.

Goals and Objectives Intervention Rationale Evaluation

3. After 10 mins of nursing intervention, the patient will be able to describe the most common complication of diarrhea – dehydration.

Discussion about dehyrdration (Background, Cause)

Dehydration is the most common effect of diarrhea.

The patient was able to describe the most common complication of diarrhea – dehydration.

4. After 10 mins of nursing intervention, the patient will be able to identify 3 out 4 signs of dehydration.

Discussion of signs of dehydration

By gaining knowledge about the signs, it is more possible to identify dehydration at present.

The patient was able to identify 3 out 4 signs of dehydration.

Goals and Objectives Intervention Rationale Evaluation

Assess the patient’s skin for signs of dehydration – poor skin turgor, dry skin and mucous membranes, and pallor.

Poor skin turgor, dry skin and mucous membranes, and increased thirst may indicate hypovolemia resulting from decreased extracellular fluid volume.

Assess and record the patient’s level of consciousness, muscle strength, and coordination at least every 8 hours. Report changes promptly.

Confusion, dizziness, or stupor may indicate hypovolemia and electrolyte imbalance. Vomiting and diarrhea can cause electrolyte loss. Sodium loss may cause confusion and delirium; potassium loss may cause muscle weakness.

Goals and Objectives Intervention Rationale Evaluation

5. After 15 mins of nursing intervention, the patient will be able to state 3 out of 5 ways on maintain adequate fluid volume in the body.

Discussion of ways on maintain adequate fluid volume (Prevention of Dehydration)

The patient may have the option to choose what intervention would be best for her. Increases patient’s independence.

The patient was able to state 3 out of 5 ways on maintain adequate fluid volume in the body.

Provide clear/bland fluids when intake is resumed. Avoid caffeinated and carbonated beverages.

More easily digested and reduce risk of added irritation to inflamed tissues.

Goals and Objectives Intervention Rationale Evaluation

Manage diarrhea through diet (BRAT)

To prevent further fluid loss

Teach the patient proper handwashing techniques and the importance of good hand hygiene after each bowel movement.

Proper handwashing is crucial to stopping the spread of infection.

Goals and Objectives Intervention Rationale Evaluation

During the acute process, teach the patient and family not to share eating utensils and items used for drinking. Also, inform family members to wipe toilet seats prior to using.

Gastroenteritis is easily transmitted to others through sharing of eating utensils and sharing toilets.

Encourage oral electrolyte solutions, as ordered or tolerated.

Helps to replace electrolytes lost.

Goals and Objectives Intervention Rationale Evaluation

6. After 10 mins of nursing intervention, the patient will be able to state in her own words the importance of adhering to prescribed therapy and medications.

Discussion of medications.

Knowledge about medications will increase client’s compliance and independence.

The patient was able to state in her own words the importance of adhering to prescribed therapy and medications.

Administer IV

fluids/ volume

expanders as

indicated; e.g.:

* PNSS

To replace active fluid loss and maintain fluid balance

Goals and Objectives Intervention Rationale Evaluation

Administer antibiotics, as ordered, after cultures have been obtained.

Helps to relieve the infection by bacteria