CHAPTER VIII Nursing Care Plan

This chapter presents the summary of the tree highest priority problems. Assessments are given to prove the diagnosis. Goals, interventions and evaluations are stated. This would indicate how well the patient responds to the prescribed therapeutic regimen.
A. Problem List

Problem Acute Pain related to inflammatory process as manifested by facial grimace

Date Identified

Time

Date Resolved

01/16/2012

8:00A.M.

1/16/2012

Diarrhea related to presence of toxins as manifested by watery stools and abdominal pain

01/16/2012

10:00A.M.

1/17/2012

Risk for Deficient fluid volume related to excess fluid volume loss as manifested by vomiting and watery stools

01/16/2012

10:30A.M.

1/17/2012

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DIAGNOSIS Subjective Cues: Sakit akong tiyan, as verbalized by the patient. Objective Cues: - Received sitting on bed; with IVF of D5IMB x 100 hooked at left arm at 50 gtts/min at 380 cc level - afebrile ; T: 36.50C - not in respiratory distress -PR:124 bpm ; RR: 23 breaths/min. (-) tenderness (+) vomiting (+) watery stools - with pain scale of 8 where 10 is the highest possible rating - with good skin turgor - weakness noted - guarding behaviour on the abdomen -facial grimace

Nursing Care Plans DESIRED NURSING NEED OUTCOME INTERVENTION General: Independent: P Within 70 of 1. Monitor and H nursing record vital Y interventions signs. S the patient I will be able to O report pain is L relieved from O pain. 2. Review factor G that I Specific: aggravate or C 1. report alleviate pain. pain is N relieved E from a E pain scale 3. Educate D of 8/10 to significant S 0/10. others on 2. follow pain prescribed reduction pharmacol techniques to ogical apply it to the regimen. patient. 3. demonstra te non4. Provide pharmacol adequate ogic 91

RATIONALE Independent: 1. To provide baseline data and note deviations from normal. 2. Helpful in establishi ng diagnosis and treatment needs. 3. To reduce pain and promote relief/comf ort.

EVALUATION Goal Met After 40 patient was able to report that pain is relieved from a pain scale of 8/10 to 0/10. She was able to follow prescribed pharmacologic al regimen. Demonstrated nonpharmacologic methods that provide relief and the use of relaxation skills and diversional activities, as indicated, for individual situation.

MODIFICATION

4. To promote healing.

Nursing Diagnosis: Acute Pain related to inflammatory process as manifested by facial grimace Background Knowledge: Gastroenteritis is the inflammation of the stomach and intestinal tract that primarily affects the small bowel. One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the bodys immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen. (Joyce M. Black, 2008)

methods rest. that 5. Provide provide diversional relief. activities like 4. demonstra playing. te use of 6. Instruct client relaxation to perform skills and deep diversiona breathing l activities, exercises as (DBE). indicated, for individual situation. 7. Monitor effectiveness of pain medications.

5. For clients comfort and relief from pain. 6. Deep breathing exercises may reduce pain sensation/ used in pain managem ent. 7. To promote timely interventio n/ revision of plan of care. Dependent: 1. To decrease abdominal pain.

Dependent: 1. Administer Zantac (ranitidine) to maintain acceptable 92

level of pain if not contraindicat ed.

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DIAGNOSIS Subjective Cues: Sige lang na siya ug libang ug basa labi na gahapon, as verbalized by the mother of the patient. Objective Cues: - Received sitting on bed; with IVF of D5IMB x 100 hooked at left arm at 50 gtts/min at 380 cc level - afebrile ; T: 36.50C - not in respiratory distress -PR:124 bpm ; RR: 23 breaths/min. (-) tenderness (+) vomiting (+) watery stools - weakness noted - increased peristalsis - abdominal pain noted Nursing Diagnosis: Diarrhea related to presence of toxins as manifested by watery

NEED P H Y S I O L O G I C N E E D S

DESIRED OUTCOME General: Within 70 of nursing interventions the patient will be able to reestablish and maintain normal pattern of bowel functioning.

NURSING INTERVENTION Independent: 1. Assess general condition and vital signs.

RATIONALE Independent: 1. To provide baseline data and note deviations from normal. 2. For presence, location, and characteri stics of bowel sounds. 3. For patient education.

EVALUATION Goal Partially Met Significant others was able to verbalized understanding of causative factors and rationale for treatment regimen and reported reduction on frequency in defecating with the characteristic of watery stool. Patient was able to demonstrate appropriate behaviour to assist with resolution of causative

MODIFICATION Continue nursing interventions due to its effectiveness but provide more health teachings regarding foods that would help towards passing out normal stool consistency.

2. Auscultate abdomen.

Specific: 1. significant others will be able to verbalize understan ding of causative factors and rationale for treatment regimen.

3. Discuss the different causative factors and rationale for treatment regimen to significant others. 4. Monitor I & O. 4. To monitor if the intake 94

stools and abdominal pain Background Knowledge: Diarrheal illness occurs when microbial virulence overwhelms normal host defenses. In addition to the ingestion of pathogenic organisms or toxins, other intrinsic factors can lead to infection. An alteration of normal bowel flora can create a biologic void that is filled by pathogens. The exact mechanism of vomiting in acute diarrheal illness is not known, although serotonin release has been postulated as a cause, stimulating visceral afferent input to the chemoreceptor trigger zone in the lower brainstem. Preformed neurotoxins produced by Staphylococcus aureus and Bacillus

2. demonstra te appropriat e behaviour to assist with resolution of causative factors. 3. significant others will be able to report reduction on frequency in defecating 4. significant others will be able to report normal and firm consistenc y of stool.

and factors. output of fluid is balanced. 5. Promote use 5. To of relaxation decrease technique. stress and anxiety 6. Encourage to 6. For fluid increase oral replaceme fluid intake nt. 7. Educate the 7. To patient about prevent the spread of importance of infectious handwashing. diseases.

Dependent: 1. Administer antidiarrheals as prescribed by the physician.

Dependent: 1. Decrease s GI motility or peristalsis and diminishes digestive secretions to relieve cramping and diarrhea.

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cereus, when ingested, can cause severe vomiting. http://emedicine.medscap e.com/article/775277overview#a0104

Collaborative: 1. Provide for changes in dietary intake

Collaborative: 1. To allow foods/sub stances that precipitate diarrhea

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DIAGNOSIS Subjective Cues: Sige lang na siya ug libang ug basa labi na gahapon, as verbalized by the mother of the patient. Objective Cues: - Received sitting on bed; with IVF of D5IMB x 100 hooked at left arm at 50 gtts/min at 380 cc level - afebrile ; T: 36.50C - not in respiratory distress -PR:124 bpm ; RR: 23 breaths/min. (-) tenderness (+) vomiting (+) watery stools - weakness noted - increased peristalsis - abdominal pain noted - dehydration - nausea Nursing Diagnosis: Risk for Deficient fluid

NEED P H Y S I O L O G I C N E E D S

DESIRED NURSING OUTCOME INTERVENTION RATIONALE General: Independent: Independent: Within 70 of 1. Monitor and 1. To provide nursing record vital baseline interventions signs. data and the patient note will be able to deviations maintain fluid from volume as normal. evidenced by 2. Monitor I & O. 2. Fluid adequate replaceme urinary nt needs output, stable are based vital signs, on moist mucous correction membranes, of current good skin deficits turgor and and capillary refill. ongoing losses. 3. Evaluate 3. Impaired Specific: clients ability gag and 1. significant to manage swallow others will own refand be able to hydration. change in verbalize level of understan conscious ding of ness are causative among 97

EVALUATION Goal Met After 70 patient was able to maintain fluid volume as evidenced by urinary output, stable vital signs, moist mucous membranes, good skin turgor and capillary refill. Significant others was able to verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications.

MODIFICATION

volume related to excess fluid volume loss as manifested by vomiting and watery stools Background Knowledge: Infectious agents usually cause acute gastroenteritis. These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production. These mechanisms result in increased fluid secretion and/or decreased absorption. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients. http://emedicine.medscap e.com/article/775277overview#a0104

factors and purpose of individual therapeuti c interventio 4. Provide skin ns and and mouth medicatio care. ns. 2. demonstra te behaviour s to monitor and correct deficit, as indicated, when condition 5. Determine is chronic. effects of 3. stabilize age. vital signs. 4. maintain the intake and output of fluid is balanced. 98

the factors that affect clients ability to replace fluids orally. 4. Skin and mucous membran es are dry with decreased elasticity because of vasoconst riction and reduced intracellul ar water. 5. Very young and extremely elderly individuals are quickly affected by fluid volume

Patient was able to demonstrate behaviours to monitor and correct deficit, as indicated, when condition is chronic and maintained the intake and output of fluid is balanced.

deficit 6. Turn frequently, gently massage skin, and protect bony prominences. 6. Tissues are susceptibl e to breakdow n because of vasoconst riction and increased fragility. Dependent: 1. Decrease s GI motility or peristalsis and diminishes digestive secretions to relieve cramping and diarrhea. 2. To deliver fluids accurately and at

Dependent: 1. Administer antidiarrheals as prescribed by the physician.

2. Administer Intravenous fluids as prescribed 99

desired rates. Collaborative: Collaborative: 1. Assist with 1. Refer to identification listing of and treatment predisposi of underlying ng or cause. contributin g factors to determine treatment needs. 2. Monitor 2. Depending laboratory on the studies. avenue of fluid loss, differing electrolyte and metabolic imbalance s may be present and require correction. 3. Ascertain 3. Relieves clients thirst and beverage discomfort preferences, 100

and set up a 7-hour schedule for fluid intake.

of dry mucous membran es and augments parenteral replaceme nt.

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