Jamie Lynn is a 19-year-old college student majoring in physical

therapy.Ms.Lynn arrives at the emergency department at 1:00 A.M.

complaining of general lower abdominal pain that had started the
previous evening. By midnight, the pain was more localized over
the right lower quadrant. She also reports nausea and vomiting.
ASSESSMENT
Sue Grady, RN, completes the admission assessment in the emergency
department.Ms. Lynn is complaining of nausea and severe
abdominal pain, stating,Walking makes my stomach hurt worse.
Physical assessment findings include:T 100.2 F (37.8 C),P 84,R 16,
and BP 110/70; skin warm to touch; abdomen flat and guarded,
with marked tenderness in right lower quadrant. Ms. Lynns complete
blood count shows WBC 14,000/mm3; neutrophils 81.1%;
lymphocytes 12.5%. The diagnosis of acute appendicitis is made,
and Ms. Lynn is transferred to surgery for a laparoscopic appendectomy.
DIAGNOSIS
The nurses in the short stay unit identify the following nursing diagnoses
for Ms. Lynn after surgery.
Impaired skin integrity, related to surgical incisions
Pain, related to surgical intervention
Anxiety, related to situational crisis
EXPECTED OUTCOMES
The expected outcomes for the plan of care are:
Incisions will heal without infection or complications.
Will verbalize adequate pain relief.
Will verbalize decreased anxiety.
Returns to preoperative activities.
PLANNING AND IMPLEMENTATION
The following nursing interventions are planned
and implemented for Ms. Lynn.
Assess pain using a pain scale; provide analgesics as needed.
Teach pain management following discharge.
Teach abdominal splinting during coughing, turning, or ambulating
as needed.
Teach home care of incisions.
Discuss activity limitations as ordered.
Instruct to report fever or warmth, redness, or drainage from
the incisions.
EVALUATION
On discharge the following evening,Ms. Lynn is fully ambulatory.
Her appetite has returned, and she is tolerating food and fluids
well. Her temperature is normal.The nurse provides Ms. Lynn with
written and verbal information on postoperative care following an
appendectomy.
Critical Thinking in the Nursing Process
1. What is the pathophysiologic basis for Ms. Lynns elevated
WBC?
2. How would Ms. Lynns postoperative care and teaching differ
if she had undergone a laparotomy instead of a laparoscopic
appendectomy?
3. Outline a teaching plan to give to clients for home care following
an appendectomy.
4. Develop a care plan for Ms. Lynn for the nursing diagnosis,
Anxiety related to a situational crisis.
See Evaluating Your Response in Appendix C.
Nursing Diagnosis: Diarrhea
Loose Stools, Clostridium difficile (C. difficile)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Bowel Elimination

Fluid Balance

Medication Response

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Diarrhea Management

Enteral Tube Feeding

Teaching: Prescribed Medications

NANDA Definition: Passage of loose, unformed stools

Diarrhea may result from a variety of factors, including intestinal absorption

disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of
the intestine. Problems associated with diarrhea, which may be acute or chronic,
include fluid and electrolyte imbalance and altered skin integrity. In elderly patients,
or those with chronic disease (e.g., acquired immunodeficiency syndrome [AIDS]),
diarrhea can be life-threatening. Diarrhea may result from infectious (i.e., viral,
bacterial, or parasitic) processes; primary bowel diseases (e.g., Crohns disease);
drug therapies (e.g., antibiotics); increased osmotic loads (e.g., tube feedings);
radiation; or increased intestinal motility such as with irritable bowel disease.
Treatment is based on addressing the cause of the diarrhea, replacing fluids and
electrolytes, providing nutrition (if diarrhea is prolonged and/or severe), and
maintaining skin integrity. Health care workers and other caregivers must take
precautions (e.g., diligent hand washing between patients) to avoid spreading
diarrhea from person to person, including self.

Defining Characteristics:
Abdominal pain
Cramping
Frequency of stools
Loose or liquid stools
Urgency
Hyperactive bowel sounds or sensations

Related Factors:
Stress
Anxiety
Medication use
Bowel disorders: inflammation
Malabsorption
 Increased secretion
Enteric infections
Disagreeable dietary intake
Tube feedings
Radiation
Chemotherapy
Bowel resection
Short bowel syndrome
Lactose intolerance

Expected Outcomes
Patient passes soft, formed stool no more than three times per
day.

Ongoing Assessment
Assess for abdominal pain, cramping, frequency, urgency,
loose or liquid stools, and hyperactive bowel sensations.

Culture stool. Testing will identify causative

organisms.

Inquire about the following:

Tolerance to milk and other dairy products Patients
with lactose intolerance have insufficient lactase,
the enzyme that digests lactose. The presence of
lactose in the intestines increases osmotic
pressure and draws water into the intestinal
lumen.
Medications patient is or has been taking Laxatives
and antibiotics may cause diarrhea. C. difficile can
colonize the intestine following antibiotic use and
lead to pseudomembranous enterocolitis; C.
difficile is a common cause of nosocomial
diarrhea in health care facilities.
Idiosyncratic food intolerances Spicy, fatty, or high-
carbohydrate foods may cause diarrhea.
Method of food preparation Fried food or food
contaminated with bacteria during preparation
may cause diarrhea.
Osmolality of tube feedings Hyperosmolar food or
fluid draws excess fluid into the gut, stimulates
peristalsis, and causes diarrhea.
Change in eating schedule
Level of activity
Adequacy or privacy for elimination
Current stressors Some individuals respond to
stress with hyperactivity of the GI tract.

Check for history of the following:

 Previous gastrointestinal (GI) surgery Following
bowel resection, a period (1 to 3 weeks) of
diarrhea is normal.
GI diseases
Abdominal radiation Radiation causes sloughing of
the intestinal mucosa, decreases usual absorption
capacity, and may result in diarrhea.

Assess impact of therapeutic or diagnostic regimens on

diarrhea. Preparation for radiography or surgery, and
radiation or chemotherapy predisposes to diarrhea by
altering mucosal surface and transit time through
bowel.

Assess hydration status, as in the following:

Input and output Diarrhea can lead to profound
dehydration and electrolyte imbalance.
Skin turgor
Moisture of mucous membrane

Assess condition of perianal skin. Diarrheal stools may

be highly corrosive, as a result of increased enzyme
content.

Explore emotional impact of illness, hospitalization, and/or

soiling accidents by providing privacy and opportunity for
verbalization.

Therapeutic Interventions
Give antidiarrheal drugs as ordered. Most antidiarrheal
drugs suppress GI motility, thus allowing for more fluid
absorption.

Provide the following dietary alterations as allowed:

Bulk fiber (e.g., cereal, grains, Metamucil)
"Natural" antidiarrheals (e.g., pretzels, matzos, cheese)
Avoidance of stimulants (e.g., caffeine, carbonated
beverages) Stimulants may increase GI motility
and worsen diarrhea.

Check for fecal impaction by digital examination. Liquid

stool (apparent diarrhea) may seep past a fecal
impaction.

Encourage fluids; consider nutritional support. Fluids

compensate for malabsorption and loss of nutrients.

Evaluate appropriateness of physicians radiograph

protocols for bowel preparation on basis of age, weight,
condition, disease, and other therapies. Elderly, frail, or
those patients already depleted may require less bowel
preparation or additional intravenous (IV) fluid therapy
during preparation.
 Assist with or administer perianal care after each bowel
movement (BM). This prevents perianal skin excoriation.

For patients with enteral tube feeding, employ the

following:
Change feeding tube equipment according to
institutional policy, but no less than every 24 hours.
Contaminated equipment can cause diarrhea.
Administer tube feeding at room temperature.
Extremes of temperature can stimulate
peristalsis.
Initiate tube feeding slowly.
Decrease rate or dilute feeding if diarrhea persists or
worsens. This prevents hyperosmolar diarrhea.

Education/Continuity of Care
Teach patient or caregiver the following dietary factors that
can be controlled:
Avoid spicy, fatty foods.
Broil, bake, or boil foods; avoid frying.
Avoid foods that are disagreeable.

Encourage reporting of diarrhea that occurs with

prescription drugs. There are usually several antibiotics
with which the patient can be treated; if the one
prescribed causes diarrhea, this should be reported
promptly.

Teach patient or caregiver the following measures that

control diarrhea:
Take antidiarrheal medications as ordered.
Encourage use of "natural" antidiarrheals (these may
differ person to person).

Teach patient or caregiver the importance of fluid

replacement during diarrheal episodes. Fluids prevent
dehydration.

Teach patient or caregiver the importance of good perianal

hygiene after each BM. Hygiene controls perianal skin
excoriation and minimizes risk of spread of infectious
diarrhea.