ASSESSMENT

DIAGNOSIS

BACKGROUND STUDY

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

Objective:

>Hyperactive bowel sounds

>vomiting

>BM (4x), watery and greenish in color

Diarrhea related to physiological factors (parasites)

Introduction of bacteria into the GI tract

Release of bacterial toxins

Disrupts the mucus lining of the stomach

Release of HCl cause gastric irritation

Increase gastric motility/peristalsis

Increase gastric motility

Frequent defecation
(DIARRHEA)

After 8 hours of Nursing Intervention, client will be able to reestablish and maintain normal pattern of bowel functioning.

Independent:

>Monitor I/O.
>Restrict solid food intake.

> Increase oral fluid intake and return to normal diet as tolerated.

Dependent:

> Administer antidiarrheal medications as indicated.

>These assessments are used to monitor volume status.

>To allow for bowel rest/ reduced intestinal workload

> To ensure adequate amt. of fluid is taken by the pt.

> To decrease gastrointestinal motility and minimize fluid loses

Goal met

After 8 hours of Nursing Intervention, client will be able to reestablish and maintain normal pattern of bowel functioning.

ASSESSMENT DIAGNO BACKGROUND PLANNING INTERVENTIO RATIONALE EXPECTED

SIS STUDY N OUTCOME
Subjective: Risk for Digestive and After 2 hrs of nursing Independent Goal Meet
deficient absorptive intervention the ct with the
>Monitor I/O >To ensure accurate After 2 hrs of
fluid malfunction help of the "SO" will be
balance, being nursing
Objective: volume able to demonstrate aware of picture of fluid status. intervention the ct
r/t behaviors to prevent altered intake with the help of the
>watery stool Increased secretion
excessiv development of fluid or output. "SO" was able to
of fluid and
>vomiting e loss of volume deficit. >To prevent demonstrate
electrolytes in the >Offer fluids
fluids occurrence of deficit behaviors to
lumen between meals
and prevent
& regularly
electrolyt development of
throughout the
es. fluid volume deficit.
Increased water day.
content of the stools >To facilitate hydration
> Promote
acompanied by
intake of high-
vomiting
water content
foods and/or
electrolyte
Imbalanced fluid and
replacement
electrolytes > Fluids may be given
drinks.
if the ct. is unable to
Dependent: take oral fluid, or when
Risk for deficient fluid rapid fluid resuscitation
>Provide
volume is required.
supplemental
Reference: fluids as > To decrease
indicated. gastrointestinal motility
MSN, LeMone and
and minimize fluid
Burke, pp 754, 757 loses

>Administer
medications
(antidiarrheals.
antiemetics) as
indicated.