NURSING CARE PLAN

DIARRHEA

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
OBJECTIVE DATA: IDENTIFIED: OBJECTIVES:  Promote bedrest  Rest decreases OBJECTIVES:
and provide intestinal
Vital Signs: Diarrhea After 8 hours of bedside motility and Patient was able to
nursing care, commode. reduces the re-establish and
BP: 165/95 mmHg patient will be able metabolic rate maintain normal
Pulse Rate: 69 bpm to re-establish and when bowel functioning.
NURSING
Respi. Rate: 15 cpm maintain normal infection is a
DIAGNOSTIC
STATEMENT: bowel functioning. complication. LONG TERM
 Hyperactive  Restrict foods as  These foods OBJECTIVES:
Bowel Sounds indicated like can add more
 Up to 10 loose Diarrhea related LONG TERM foods containing irritation to The patient did not
to semi-solid to gastro- OBJECTIVES: caffeine , too the stomach experience an
stools/day, non- intestinal much oil, fiber , episode of loose
bloody inflammation as After three days or milk and fruits stool
 Patient evidenced by until discharged  Observe and  This will help
experience the patient will not record stool differentiate
abdominal pain.
some mild have an episode of frequency, individual
fatigue loose stool characteristics, disease and
amount, and assesses
precipitating severity of
factors. episode
 Restart oral fluid  This will
intake gradually. provide colon
Offer clear liquids rest by
hourly, and avoid omitting or
cold fluids. decreasing
stimulus of
foods or
fluids. Gradual
 consumption
CAUSE ANALYSIS: of liquids may
prevent
Damaged intestinal cramping and
wall tissue recurrence of
diarrhea. Cold
fluids can
Loss of ability to increase
absorb water intestinal
motility.
 Observe for the  This will help
More water to be presence of to assess the
excreted causative
associated factors
factors and
such as
etiology.
Diarrhea abdominal pain,
bloody stools,
cramping or
In people with emotional upset.
Crohn’s Disease,  Educate the  The anal area
the digestive tract should be
patient about the
becomes inflamed gently clean
even when there is perineal care
properly after
not an infection. after each bowel a bowel
The inflammation movement. movement to
often leads to prevent skin
symptoms such as irritation and
diarrhea. Diarrhea transmission
can be one of the of
more unsettling microorganis
and brothersome m
symptoms of  Avoiding
Crohn’s Disease  Identify foods intestinal
(Healthline.com) and fluids that irritants
precipitate promotes
diarrhea intestinal rest
DEPENDENT:
 Take anti  Decrease GI
diarrheal motility or
medications as peristalsis and
prescribed. diminishes
digestive
secretions to
relieve
cramping and
diarrhea.
These drugs
coat the
intestinal wall
and absorb
bacterial
toxins

COLLABORATIVE:
 Submit client’s  A culture is a
stool for culture. test to detect
which
causative
organisms
cause an
infection.
 Encourage  When a client
patient to eat experience a
foods rich in diarrhea, the
potassium as stomach
prescribed by the contents
nutritionist which is high
in potassium
get flushed
out of the
gastrointesti-
nal tract into
the stool and
out of the
 body,
resulting in
hypokale-mia

ACUTE PAIN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE DATA: PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
IDENTIFIED: OBJECTIVES:  Provide measures  It is preferable to OBJECTIVES:
Vital Signs: to relieve pain provide an
Abdominal Pain At the end of 8 before it becomes analgesic before The patient
BP: 165/95 mmHg hours of duty, the severe the onset of pain verbalized
Pulse Rate: 69 bpm patient will or before it reduction of pain
Respi. Rate: 15 cpm NURSING verbalize becomes severe from a pain scale
DIAGNOSTIC reduction of pain when a larger of 4 in q 0-10
 Guarding STATEMENT: from a pain scale dose may be scale with 10 as
with of 4 in q 0-10 required the most painful
pressure to Acute Pain scale with 10 as  Acknowledge and  Nurses have the
right lower related to the most painful accept the client’s duty to ask their
quadrant pain clients about their
inflammation as
 Patient pain and believe LONG TERM
experience evidenced by LONG TERM their reports of OBJECTIVES:
some mild guarding OBJECTIVES: pain. Challenging
fatigue behavior or undermining The patient
 Mild After three days their pain reports demonstrated
arteriolar or until discharge in an unhealthy ways to reduce
narrowing on of the patient will therapeutic pain
funduscopic demonstrate relationship
exam without ways to reduce  Determine and  Acute pain is that
hemorrhages, pain document which follows or
exudates, or presence of occurs suddenly
papilledema possible with onset of
pathophysiological painful condition
and psychological (Crohn’s Disease)
causes of pain (e.g
inflammation or
 infections)

CAUSE ANALYSIS:  Assess for referred  To help

pain as determine
Unregulated appropriate possibility of
inflammation underlying
condition or
organ dysfunction
Damaged requiring
Gastrointestinal treatment
tissue
 Evaluate pain  Use pain rating
characteristics and scale appropriate
Pain in affected intensity for age and
area cognition (0-10
scale)
Intermittent,  Perform pain  This
partial small assessment each demonstrates
bowel time pain occurs. improvement in
obstruction in Document and status or to
Crohn’s Disease investigate identify
changes from worsening of
can frequently previous reports underlying
cause pain and evaluate condition/develo
(Docherty, M. results of pain ping
2011) intervention complications
 Provide comfort  To promote non
measures and calm pharmacological
activities pain management
 Instruct and  To prevent
encourage use of fatigue
relaxation
techniques
 Perform proper  Appropriate
nursing measures is best
interventions and to prevent
appropriate complications
procedures to
 alleviate pain

DEPENDENT:
 Take analgesics, as  To maintain
indicated, to “acceptable” level
maximum dosage of pain. Notify
as needed physician if
regimen is
inadequate to
meet pain control
goal.
Combinations of
medications may
be used on
prescribed
intervals
COLLABORATIVE:

 Evaluate  To check for any

laboratory results imbalances

DEFICIENT FLUID VOLUME

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM SHORT TERM INDEPENDENT: SHORT TERM
OBJECTIVE DATA: IDENTIFIED: OBJECTIVES:  Monitor and  These changes OBJECTIVES:
record vital signs in vital signs
Vital Signs: Dehydration After 8 hours of are associated .The patient was
nursing with fluid able to able to
BP: 165/95 mmHg interventions, volume loss exhibit moist
Pulse Rate: 69 bpm patient will:  Observe or  Note the color. mucous membrane
NURSING
Respi. Rate: 15 cpm DIAGNOSTIC  able to measure urinary May be dark and good skin
STATEMENT: exhibit output greenish turgor
moist brown
 Warm and mucous because of LONG TERM
Deficient fluid
 dry skin with volume related membrane concentration OBJECTIVES:
flakiness to active fluid and good  Adequate rest  To avoid
 Poor skin volume loss as skin turgor and sleep should exhausting the The patient
turgor be provided patient, this maintained fluid
 Dry mucous
evidenced by may lead volume at a
membranes poor skin turgor LONG TERM more on fluid functional level
 Patient and dry mucous OBJECTIVES: loss demonstrate
experience membrane  Provide proper  To avoid other behaviors to
some mild After three days or ventilation and fluid loses monitor and
fatigue CAUSE ANALYSIS: discharge, the cool environment through correct deficit, as
patient will: excessive indicated
Damaged intestinal sweating
wall tissue  maintain  Provide frequent  To limit
fluid oral as well as gastric or
volume at a eye care intestinal
Loss of ability to functional losses
absorb water level  Assess skin  Fluid loss
demonstrat turgor, mucous occurs first in
e behaviors membrane every extracellular
Active fluid volume to monitor shift spaces,
loss and correct resulting in
deficit, as poor skin
indicated turgor and dry
Prolonged diarrhea mucous
membrane
DEPENDENT:
Dehydration
 Change position  To reduce
frequently pressure on
Fluid Volume fragile skin
deficit or and tissues
hypovolemia  Take medications  To prevent
occurs from a (antidiarrheals) injury from
loss of body fluid as prescribe dryness
or the shift of
fluids into the
third space, or
from a reduced
fluid intake. COLLABORATIVE:
Common
 Review  This will be
sources for fluid laboratory data used to
loss are the (e.g. evaluate the
gastrointestinal haemoglobin, body’s
(GI) tract. prothrombin response to
time, activated fluid loss and
partial to determine
thrompoblastin replacement
time, electrolytes needs.
(sodium,
potassium,
chloride,
bicarbonate)
 IVF administered  To deliver
as ordered. fluids
Maintained at accurately at
proper regulation desired rates