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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 clients pain will be relieved as evidenced by a pain scale of 2/10
Objectives: 1. After 5 mins of Independent:

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

Note reports of nursing intervention, pain, including the patient will be location, duration, able to describe the intensity(1-10 pain she experiences.

Pain is not always present, but if the present should be compared with the clients 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 Helpful in establishing that aggravate or diagnosis and treatment alleviate pain. 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 2. After 15 mins of

Intervention

Rationale

Evaluation

Discussion of nursing intervention, pain the patient will be management able to state 3 out of techniques 5 pain management techniques.

It will facilitate patients 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 Prompt responses to immediately to complaints may result in complaint of pain decreased anxiety in the patient. Demonstrated concern for patients 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

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

Knowledge about medications will increase clients 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.

ASSESSMENT
Subjective 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

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

Acquiring adequate knowledge about the condition will facilitate patients 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/ To be able to plan precipitating nursing action factors

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 2. After 10 mins of

Intervention

Rationale

Evaluation

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

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 Provides information accurate record about fluid status. of I&O, noting output less than intake and assess skin/ mucuos membranes.

Goals and Objectives 3. After 10 mins of

Intervention

Rationale

Evaluation

Discussion about nursing intervention, dehyrdration the patient will be (Background, able to describe the Cause) most common complication of diarrhea dehydration.

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

By gaining knowledge The patient was able about the signs, it is to identify 3 out 4 more possible to identify signs of dehydration. dehydration at present.

Goals and Objectives

Intervention

Rationale

Evaluation

Assess the patients skin for signs of dehydration poor skin turgor, dry skin and mucous membranes, and pallor.
Assess and record the patients level of consciousness, muscle strength, and coordination at least every 8 hours. Report changes promptly.

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

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 5. After 15 mins of

Intervention

Rationale

Evaluation

Discussion of nursing intervention, ways on maintain the patient will be adequate fluid able to state 3 out of volume 5 ways on maintain (Prevention of adequate fluid Dehydration) volume in the body.

The patient may have the option to choose what intervention would be best for her. Increases patients 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 To prevent further fluid through diet loss (BRAT)

Teach the patient Proper handwashing is proper crucial to stopping the handwashing spread of infection. techniques and the importance of good hand hygiene after each bowel movement.

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 6. After 10 mins of

Intervention

Rationale

Evaluation

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

Knowledge about medications will increase clients 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