Clients Initials:

J.C.

Medical Diagnosis:

Lactose intolerance

ASSESSMENT
Assessment Data
Objective data:

Asiatic descent male.

Urine specific gravity

WNL.

Height 52

Weight 52.7 kg

Pink and moist mucus

membranes.

Capillary refill is less

than 3 seconds.

Abdomen is soft with

hyperactive bowel
sounds.
Subjective Data:

18 years-old college
freshman student.

Patient (pt) lives in a

communal dormitory.

Occasional difficulties
with diarrhea in the past,
with loose, watery
stools.

Pt C/O worsened
diarrhea over the last 6
months, since the
beginning of the school
year.

Pt reports 4-6 large,

loose stools per day with
severe abdominal
cramping.

Pt describes his stools as

foul smelling and
accompanied by a great
deal of flatus.

Pt finds this problem

very embarrassing.

Pt has changed his diet

from a fairly traditional
Chinese diet with few
milk products when he
lived at home to meals
in the dormitory dinning
room where he feels less
able to control the
amount of milk products
in his diet.

3 day diet recall shows a

Student Name:

Paloma Garcia Duran

Date:

NURSING DIAGNOSIS
Nursing Diagnosis and
Rationale for Etiology

Patient Goal &

Outcome Criteria

Nursing Dx: diarrhea.

Diarrhea is the priority
nursing dx because it puts
patient in risk for:

Malnutrition.

Electrolyte imbalance.

Deficient fluid volume

related to:

Change in diet.

Gastrointestinal
disorders.

Stress.
as manifested by:

Reported 4-6 large,

loose stools daily.

Severe abdominal
cramping.

Deficient knowledge
about alimentary
products that contain
lactose, which he has
been medical diagnosed
to be intolerant.
(Ackley & Ladwig, 2014, pp.
46, 73)

The patient will:

Be able to identify
alimentary products
containing lactose by
3/7/2015.

Learn how to
maintain a balanced
diet by 3/7/2015.
as evidenced by:
1. Reduced number of
defecations from 4-6 to 1
every 1 to 3 days with soft
and formed stools within 2
weeks and maintained for
the next 6 months.
2. Increased knowledge on
alimentary products
containing lactose
manifested by passing
identification quizzes with
90% and above in daily
basis for a week.

PLANNING
Nursing Interventions
(assess, teach, treat,
prevent)
The nurse will:
Assess:
1. The number of
defecations and the stools
characteristics every day
for a week. The first day,
the nurse will personally
assess them by direct
observation and the
following 6 days by asking
the patient at bedtime.
2. For dehydration by
observing skin turgor,
excessive thirst, fever,
dizziness, lightheadedness,
palpitations, excessive
cramping, bloody stools,
hypotension, and
symptoms of shock every
day before breakfast for a
week.
3. The abdominal pain
level and distention before
and after 30 minutes and 2
hours each meal for a
week.
Teach:
4. Pt how to identify
alimentary products
containing lactose and how
to eat a balanced diet by
teaching him which foods
contain lactose, how to
read nutrition labels, and
how to use Myplate.gov to
create weekly balanced
diets. This teaching will be
performed at 1800 every
day for a week and after
each lesson an
identification quiz will be
proportionated to assess the
knowledge acquired.
Treat:
5. Independently: Fluid
loss by encouraging patient
every morning for a week
to drink 3000 ml (12
glasses of water) every day.
6. Dependently: if nurse

Rationale for
Interventions
1. Assessment of
defecation pattern will help
direct treatment. Nurses
are important in the early
recognition, diagnosis, and
prompt treatment if clients
have C. difficile.
Recognition can prevent
life-threatening
complications such as
colitis, toxic megacolon,
perforations, and sepsis.
(Ackley & Ladwig, 2014,
p.304)
2. Severe diarrhea can
cause deficient fluid
volume with extreme
weakness and a possible
shock state. (Ackley &
Ladwig, 2014, p. 306)
3. The acute onset of
abdominal distention in
conjunction with symptoms
of cramping pain, weight
loss, nausea, vomiting,
obstipation, or diarrhea
warrants further
evaluation for disorders
that cause intestinal
obstruction. (Ackley &
Ladwig, 2014, p. 380)
4. Dietary guidelines are
written by national experts
and are based on research
in nutrition.
(Ackley & Ladwig, 2014,
p. 555)
5. The adequate intake
recommendation is 3 L for
the 19- to 30-year-old male
and 2.2 L for the 19- to 30year-old female. Water
balance studies suggest
that adult men require 2.5
L per day. (Ackley &
Ladwig, 2014, p. 556)
6. Use of a fiber
supplement decreases the
number of incontinent
stools and improves stool

3/1/2015

IMPLEMENTATION
OF INTERVENTIONS

EVALUATION OF
GOALS AND
OUTCOME
CRITERIA

Plans 1, 2, 3, 4, 5, 6,
and 7 will be
implemented by the
registered nurse.
Plan 6 requires a
physician or nurse
practitioner order.
Plan 7 will be partially
implemented by a
registered dietitian.

Outcomes met:
__________ total
__________ partial
__________ none
Goal: Met/Not Met
Revision of plan of care:

significant intake of
milk products, including
cheese, yogurt, and
milk-based foods.
Maslows Basic Need:
Physiological needs
unsatisfied because pt is not
receiving an adequate
nutrition, which is also
affecting his fluids needs.
(Wilson & Giddens, 2013, p.
70)
Eriksons Developmental
Stage:
Pt is in Identity vs. Role
Confusion stage because pt
just left family home to start a
new life on his own and is
discovering who he is.
(Potter, 2013, pp. 131, 132)

detects that chronic

diarrhea has caused fecal
incontinence, consult with
primary practitioner for
implementing the use of
dietary fiber from psyllium
or gum Arabic Stat.
7. Collaboratively:
Electrolyte imbalance and
malnutrition by
collaborating with a
nutritionist/dietitian in
elaborating a diet for the pt
Stat.
This interventions will help
prevent malnutrition,
electrolyte imbalance, and
deficient fluid volume.

consistency. Soluble
dietary fiber is useful for
controlling diarrhea and
normalizing the intestinal
flora. (Ackley & Ladwig,
2014, p. 306)
7. Refeeding syndrome, a
potentially fatal condition,
occurs in some
malnourished clients when
nutrients are given in
excess of the clients ability
to metabolize them. Clients
at risk of refeeding
syndrome must be
monitored carefully for
electrolyte imbalances,
congestive heart failure,
and respiratory failure.
(Ackley & Ladwig, 2014,
p. 561)

References:
Wilson, S., & Giddens, J. (2013). Health assessment for nursing practice (5th ed.). Mosby. VitalBook file.
Ackley, B. & Ladwig, G. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.). Mosby. VitalBook file.