Section P– Group 1

E.C.S. – Pediatric Ward

RLE (Period covered: July 27-Aug. 1,2009)
Mr. Ralph P. Pilapil, R.N.
Clinical Instructor
 A. Nursing History
Identifying Data

Name of Patient : Patient X

Sex : Male
Age : 16 years old
Civil Status : Single
Nationality : Filipino
Religion : R.C.
Address : Sta. Cruz, Guizo Mandaue City
Occupation : Student
Date Admitted : July 27, 2009
Time : 8:10 p.m.

Informant : Mother
Age : 30 years old
Physician : Dr. Pitogo
Room : Pediatric Ward
 Admission Data

Source of Information : Mother

Mode of Admission : Ambulatory

Vital Signs on Admission

Temperature: 36.6°C
Heart Rate : 60 bpm
Respiratory Rate : 18 cpm
Blood Pressure : 120/70 mm Hg
Weight : 56 kg
Height : 5’ 4”
Chief of Complaints: LBM, pain and vomiting
 History of Present Illness

Two days PTA, The patient defecated watery

stools more than 5 times with nausea and vomiting.
The following day, Monday, client still defecated
watery stool in succession and was partially relieved
after taking Diatabs. After several hours LBM
reoccur with occasional vomiting. Thus, patient’s
mother saught medical advise resulting to his
admission.
 Past Medical History

The client experienced severe diarrhea last January 2004 and was
hospitalized.

Injuries:
• No previous injuries

Operation:
• No minor and major operation were performed
Family Medical History:
Negative in: Heart Disease
Diabetes Mellitus
Hypertension
Cancer
Congenital Anomalies
Obesity
Arthritis
Seizure
Tuberculosis
 Physical Assessment
1. EENT
 Eye functioned well and responsive to light accommodation (3-
4mm)
 tonsils are pink and in normal size

2. Central Nervous System

 able to speak the words clearly (responsive)
 irritability noted
 negative presence of seizure or tremors
 weak hand grasping and movement

3. Cardio Vascular System

 weak capillary refill
 blood pressure of 100/60
 regular heart rhythm
4. Respiratory System
 symmetric chest expansion
 clear breath sound

5. Gastrointestinal System
 presence of hyperactive bowel sound
 excessive bowel elimination (five times/day)
 facial grimacing noted during defecation
 palpated with soft abdomen/tender
 pain sensation at anal area due to irritation from frequent defecation
 excessive loose / watery stool with fecal particles
 Dry skin & poor skin turgor
 Sunken eye ball

6. Genito-Urinary System
 disturbed sleeping pattern due to nocturnal urination
 low urine output (25ml/hour)
 reddish urine color
7. Integumentary System
 poor skin turgor
 rough / dry skin
 responsive to pain

7. Musculoskeletal System
 can stand and sit on his own with signs of weakness
 poor tendon reflex
 Laboratories Performed
Date Ordered: July 27, 2009

Fecalysis
Urinalysis
Specimen Data Report
 FECALYSIS
Diagnostic Normal Value Result Significance
Color Yellow Reddish Presence of
components that
indicates infection
Consistency Soft Watery Sign of dehydration

Cellular Findings
RBC None Not Seen Normal
Pus Cells 0-2 0-1/Hpf Normal
Bacteria None Many Infection is present

Yeast Cells Rare Normal

 URINALYSIS
Diagnostic Normal Value Result Significance
Color Clear Yellow
Transparency Clear Clear
Ph 6-7.5 6.0 Normal
Specific Gravity 1.010-1.025 1.025 Normal
Protein Negative Negative Normal
Sugar Negative Trace w/in normal range
Microscopic Exam:
Pus Cells 0-2 3-6 Infection present
RBC 0-1 0-1 Normal
Epithelial Cells - Few Normal
A. Urates - Few Normal
A. Phosphates - - -
Bacteria - Moderate Infection
Mucus Thread - Few Normal
Ca Oxalates - Moderate Normal
 SPECIMEN DATA REPORT
Diagnostic Normal Value Result Significance
WBC 5-10/109L 14.0 Increased WBC
count indicates
infection
 B. Anatomy & Physiology
• Organs affected
• Functions
• Growth and development according to the
age of client
Digestive System
 ESOPHAGUS
• Approximately 25 cm (10inches long) but its
diameter depends on how much food it contains.
• When its full, it can hold about 4 liters of food; when
empty, it collapses and its mucosa is thrown into
large folds called rugae.
• Esophageal peristalsis propels the bolus of food
into the stomach through the cardiac sphincter
STOMACH
– A distendible pouch with a capacity of about 1500
mL
– 4 anatomic regions
– Stores and mixes food with the enzyme-
containing gastric juice.
– Produces protein digesting enzymes –
pepsinogen, mucus, intrinsic factor and
hydrochloric acid.
– Food stays from a half hour to several hours
– Chyme, which is food mixed with secretions
enters the small intestine through the pyloric
sphincter
The small intestine is the longest and most convoluted
portion of the digestive tract
• Measuring 16 to 19 feet ( 5 to 6m) in length in an adult.
• Composed of three different regions:
- duodenum,
- jejunum, and
- ileum.
• The inner surface of the small intestine has a velvety
appearance because of numerous mucous
membrane finger like projections called intestinal villi.
• Pancreatic secretions: trypsin, amylase and lipase
• Intestinal glands secrete mucus, hormones and
electrolytes that coats the
 Function:
Three main functions:
– movement (mixing and peristalsis)
– digestion
– absorption
LARGE INTESTINE

– about 5 to 6 feet in length from the ileocecal valve

to the anus
– lined with columnar epithelium that has absorptive
and mucous cells.
– it begins with the cecum, a dilated pouchlike
structure that is inferior to the ileocecal opening.
– the large intestine then extends upward from the
cecum as the colon.
– the colon consist of four divisions:
- ascending colon
- transverse colon
- descending colon
- sigmoid colon.
 Function:
Three Main Functions:
– Absorption
– Elimination
– Movement
 DIAGNOSIS AND DEFINITION

GASTROENTERITIS:
• Is an increase in the frequency and water
content of stools or vomiting as a result of
inflammation of the mucous membranes of
the stomach and intestinal tract.

• Primarily affects the small bowel and can be

either viral or bacterial origin.
 C. Pathophysiology
Risk Factors:
Precipitating Factors:
•Children
•Poor sanitation during warm months
•Older adults
•Crowded living conditions
•Familial tendency

Etiology
Bacteria

Signs and Symptoms Diagnostic Evaluation

•Watery stools DIAGNOSIS •Fecalysis
•Intestinal rumblings Acute Gastroenteritis •Urinalysis
•Abdominal pain •Specimen Data Report
•Distention
•Vomiting
•Fever
Release of enterotoxins and attachment of organism to mucosal
epithelium

GI wall irritation and destruction of intestinal villi

Fluid secreted into lumen

Increased fluid in the GI lumen and reduction of absorption

OUTCOME
HYPOVOLEMIA Complications
•SHOCK
- renal failure
PROGNOSIS - irreversible acidosis

The pt. was responsive

DEATH to the therapeutic mgt.
Signs and Symptoms:
– Diarrhea
Explanation:
The epithelium of the digestive tube is protected
from insult by a number of mechanisms
constituting the gastrointestinal barrier, but like
many barriers, it can be breached. Disruption of
the epithelium of the intestine due to microbial
or viral pathogens is a very common cause of
diarrhea in all species. Destruction of the
epithelium results not only in exudation of
serum and blood into the lumen but often is
associated with widespread destruction of
absorptive epithelium. In such cases, absorption
of water occurs very inefficiently and diarrhea
results.
Abdominal pain or cramp
Explanation:
The pain associated with obstruction of a hollow viscus
(as opposed to peritoneal and solid organ pain) is often
intermittent or "colicky", coinciding with the peristaltic
waves of the organ. Such cramps are exactly what is
experienced with early acute appendicitis and
gastroenteritis and are somewhat relieved by writhing
and massage
Vomiting
Explanation:
Vomiting in diarrhea can occur when the lining of the
intestines or stomach is irritated by an infection. Usually
the infection is caused by a virus or bacteria. Diarrhea
and vomiting can drain water and salts from the
patient. These need to be replaced to prevent the patient
from becoming dehydrated (dry).
 D. Medical Managements
I. DIAGNOSTIC / LABORATORY PROCEDURES

Ideal:
• Complete Blood Count
• Urinalysis
• Routine stool examination
• Stool Culture
• Barium enema

Actual:
• Urinalysis
• Fecalysis
Complete Blood Cell Count
Importance of CBC
A complete blood count may be done as part of a regular physical examination.
A blood count can give valuable information about the general state of your
health. While there are many different types of cells in your blood, they can all
be grouped into one of three categories: red blood cells, white blood cells, and
platelets.
White Blood Cells (WBC)
A high white blood cell count likely indicates that an infection is present
somewhere in the body, whereas a low number might indicate that an infection
or disease has slowed the ability of the bone marrow to produce new WBCs.
Red Blood Cells (RBC)
A low red blood cell count can indicate anemia, which can lead to fatigue. If the
count is too high (a condition called polycythemia), there is a chance that the
red blood cells will clump together and block tiny blood vessels (capillaries).
This also makes it hard for your red blood cells to carry oxygen.
Hemoglobin (HGB) and Hematocrit
For men, the hematocrit should be between 40% and 52%; for women, it
should be between 35% and 46%. A low hemoglobin number or hematocrit
percentage are good indicators of anemia.
Platelets
If there are too few platelets, uncontrolled bleeding may be a problem. If there
are too many platelets, there is a chance of a blood clot forming in a blood
vessel. Also, platelets may be involved in hardening of the arteries.
How is it done?
Your health professional drawing blood will:
– Wrap an elastic band around your upper arm to stop
the flow of blood. This makes the veins below the
band larger so it is easier to put a needle into the
vein.
– Clean the needle site with alcohol.
– Put the needle into the vein. More than one needle
stick may be needed.
– Attach a tube to the needle to fill it with blood.
– Remove the band from your arm when enough blood
is collected.
– Put a gauze pad or cotton ball over the needle site as
the needle is removed.
– Put pressure to the site and then a bandage.
Urinalysis
A urinalysis tests the urine for color, clarity (clear or
cloudy), odor, concentration, and acidity (pH). It also
checks for abnormal levels of protein, sugar, and
blood cells or other substances that, if found in the
urine, may indicate an illness or disease somewhere
in the body. A regular urinalysis often includes the
following tests:
• Color
• Clarity
• Odor
• Specific gravity
• pH
• Protein
• Glucose
• Nitrites
• Ketones
How It Is Done
Clean-catch midstream one-time urine collection
• Wash your hands to make sure they are clean before collecting the
urine.
• If the collection cup has a lid, remove it carefully and set it down with
the inner surface up. Do not touch the inside of the cup with your
fingers.
• Clean the area around your genitals.
• A man should retract the foreskin, if present, and clean the head of
his penis with medicated towelettes or swabs.
• A woman should spread open the genital folds of skin with one hand.
Then use her other hand to clean the area around the urethra with
medicated towelettes or swabs. She should wipe the area from front
to back so bacteria from the anus is not wiped across the urethra.

– After the urine has flowed for several seconds, place the collection cup
into the urine stream and collect about 2 fl oz of this “midstream” urine
without stopping your flow of urine.
– Do not touch the rim of the cup to your genital area. Do not get toilet
paper, pubic hair, stool (feces), menstrual blood, or anything else in the
urine sample.
– Finish urinating into the toilet or urinal.
– Carefully replace and tighten the lid on the cup then return it to the lab. If
you are collecting the urine at home and cannot get it to the lab in an
hour, refrigerate it.
Stool Culture
A stool culture is done to:
• Find the cause of symptoms, such as severe diarrhea,
an increased amount of gas, nausea, vomiting, loss of
appetite, bloating, abdominal pain and cramping, and
fever.
• Find and identify certain types of bacteria, viruses,
fungi, or parasites that are causing infections or
diseases
• Identify a person who may not have any symptoms of
disease but who carries bacteria that can spread
infection to others. This person is called a carrier. A
person who is a carrier and who handles food is likely
to infect others.
• Find out if treatment for an infection has been effective
Collect the sample as follows:

– Urinate before collecting the stool so that you do not get any urine in the
stool sample. Do not urinate while passing the stool.
– Put on gloves before handling your stool. Stool can contain material that
spreads infection. Wash your hands after you remove your gloves.
– Pass stool (but no urine) into a dry container. You may be given a plastic
basin that can be placed under the toilet seat to catch the stool.
– Either solid or liquid stool can be collected.
– If you have diarrhea, a large plastic bag taped to the toilet seat may make
the collection process easier; the bag is then placed in a plastic
container.
– If you are constipated, you may be given a small enema.
– Do not collect the sample from the toilet bowl.
– Do not mix toilet paper, water, or soap with the sample.
– Place the lid on the container and label it with your name, your doctor's
name, and the date the stool was collected. If you are collecting more
than one sample, use one container for each sample, and collect a sample
only once a day unless your doctor gives you other directions.
– Take the sealed container to your doctor's office or the laboratory as soon
as possible. You may need to deliver your sample to the lab within a
certain time. Tell your doctor if you think you may have trouble getting the
sample to the lab on time.
Barium Enema
A barium enema, or lower gastrointestinal (GI)
examination, is an X-ray examination of the
large intestine (colon and rectum). The test is
used to help diagnose diseases and other
problems that affect the large intestine. To
make the intestine visible on an X-ray picture,
the colon is filled with a contrast material
containing barium. This is done by pouring the
contrast material through a tube inserted into
the anus. The barium blocks X-rays, causing
the barium-filled colon to show up clearly on
the X-ray picture.
II. MEDICATIONS
Actual:

• Ranitidine HCl (Zantac) 80mg slow IVTT

q8h – Antiulcer Agent
• Ciprofloxacin HCL 500mg 1tab BID PO
PC - Anti Infective Agent
• Aluminum Magnesium Hydroxide(Isopan)
20 ml 1pc 2 H.S. - Antacid Agent
• Drug Name : Cefotaxime (Claforan)
Classification :
Third-generation parenteral antibiotic with
wide coverage, including gram-negative
bacilli.

Mechanism of Action :
Arrests bacterial cell wall synthesis, which,
in, turn inhibits bacterial growth
• Drug Name : Rifaximin (Xifaxan, RedActiv,
Flonorm)
Classification :
Nonabsorbed (<0.4%), broad-spectrum antibiotic
specific for enteric pathogens of the gastrointestinal
tract (ie, gram-positive, gram-negative, aerobic,
anaerobic).

Mechanism of Action :
Binds to beta-subunit of bacterial DNA-dependent
RNA polymerase, thereby inhibiting RNA synthesis.
Indicated for E coli (enterotoxigenic and
enteroaggregative strains) associated with
travelers' diarrhea.
III. TREATMENT

Ideal:
• Oral rehydration therapy
• Antimicrobial therapy
• E coli: Antibiotic treatment

Actual:
• D5LR 1 Liter @ 30 gtts/min
• Monitoring of urine and stool
• V/S q shift
IV. EXERCISES AND ACTIVITIES
• Ambulate by himself w/o the assistance
of S.O.

V. DIET
Ideal:
• The bland diet
• Introduce lean meats and clear fluids as
soon as possible.
Actual:
• DAT
 MEDICATIONS
Medications are
substances used in the
diagnosis, treatment, cure,
relief, or prevention of
health alterations. This is
the primary treatment
client associate with
Name of Drug Date Classification Dose Frequency
Generic Ordered Route
(Brand)

Ranitidine 7/27/09 Anti ulcer drug 80 mg, slow IVTT q8 hr

HCL
(Zantac)

Mechanism of Specific Side Effects Nursing Implications

Action Indication
Competitively Gastro esophageal CNS: vertigo, Before :
inhibits action of reflux disease malaise, headache. Assess patient for abdominal pain,
histamine on the EENT: blurred vision note for presence of blood & emesis &
H2 @ receptor Contraindications: stool.
Hepatic: jaundice During:
sites , parietal -patient with
cells decreasing hypersensitive to Other: burning and Administer IVTT slowly.
gastric itching @ injection After:
drug & those with
secretion. phorphyria. site anaphylaxis, Monitor patient for adverse reaction.
angioedema.
-Use cautiously in Store IV injection @ 30 degrees
patient with hepatic After dilution solution is stable for 48
dysfunction. hrs. @ room temperature.
-adjust dosage in After taking the medication advise pt to
patient with impaired report immediately any adverse
renal function reactions.
Name of Drug Date Classification Dose Frequency
Generic Ordered Route
(Brand)
Ciproflaxacin 7/27/09 Anti -Infective 500 mg/tab BID PO pc
HCL
Mechanism of Specific Indication Side Effects Nursing Implications
Action
Inhibits bacterial Complicated intra- EENT: local Before:
DNA, an enzyme abdominal infection. burning or -Assess vital sign.
needed for discomfort, foreign -Assess lab. Results and the
bacterial body sensation, causative agent.
Contraindications:
replication. itching.
-Hypersensitive to a During:
GI: bad or better
ciproflaxacin. -Stop drug @ first sign of any
taste in mouth.
--it’s unknown if drug hypersensitivity.
appears in breast milk After:
after application. -Prolonged use may result in
overgrowth of susceptible organisms.
-Assess for adverse reaction.
Name of Drug Date Classification Dose Frequency
Generic Ordered Route
(Brand)
Aluminum 7/27/09 antacids Susp. 20 ml pc 2 H.S.
Magnesium
Hydroxide
(Isopan)
Mechanism of Specific Side Effects Nursing Implications
Action Indication
Reduces total acid Acid indigestion . GI: mild constipation, Before:
load in GI tract, Contraindications: diarrhea. -Assess patient with renal failure.
elevates gastric ph •Severe renal disease. GU: increased urine -Instruct patient not to take suspension
to reduce pepsin ph.
•Use cautiously in or liquid well and follow dose with
activity
patients with mild Metabolic: water.
strengthens hypokalemia
gastric mucosal renal impairment. During:
barrier, and -monitor magnesium level in patient
increases with mild renal impairment.
esophageal After :
sphincter tone. -Urge patient to notify prescriber about
the signs or symptoms of GI bleeding,
such as tarry stools & coffee ground
vomiting.
Nursing Management
 Deficient Fluid Volume
I. Goal of Care: To assess causative/precipitating factors:
– Determine effects of age.

II. Goal of Care: To correct/replace losses to reverse

pathophysiological mechanisms.
– Establish 24 hour fluid replacement needs and routes to be
used.

III.Goal of Care: To promote comfort and safety:

– Provide frequent oral care as well as eye care.
– Administer medications.
 Acute Pain
I. Goal of Care: To evaluate client’s
response to pain:
– Perform pain assessment each time pain
occurs.
– Accept client’s description of pain.
– Assess for referred pain as appropriate..
II. Goal of Care: To assist client to explore methods
for alleviation/control of pain:
– Review/expectations and tell client when treatment will hurt.
– Administer analgesics as indicated to maximal dosage as
needed.
– Assist client to alter drug regimen, based on individual
needs.

III. Goal of Care: To promote wellness

(Teaching/Discharge Considerations):
– Encourage adequate rest periods.
– Provide for individualized physical therapy/ exercise program
that can be continued by the client when discharged.
 Risk for Imbalanced Nutrition
I. Goal of Care: To assess
causative/contributing factors:
– Ascertain understanding of individual
nutritional needs.
– Discuss eating habits, including food
preferences, intolerance /aversions.
– Assess drug interactions, disease effects,
allergies, use of laxative, diuretics.
– Determine psychological factors/perform
psychological assessment as indicated.
II. Goal of Care: To establish a nutritional plan that
meets individual needs:
– Assist in developing individualized regimen.
– Consult dietitian/nutritional team as indicated.
– Limit fiber/bulk if indicated.
– Prevent/minimize unpleasant odors/sights.
– Encourage client to choose foods that are appealing.

III. Goal of Care: To promote wellness

(Teaching/Discharge Considerations):
– Weigh weekly and document results
– Refer to home health resources and so on
– Consult with dietitian/nutritional support team as necessary
 Nursing Care Plan 1
ASSESSMENT

SUBJECTIVE:
– “tubig gihapon ako gikalibang” as
verbalized by the pt.

OBJECTIVE:
– excessive loose / watery stool
– Dry skin & poor skin turgor
– Sunken eye ball
– excessive bowel elimination (five times/day)
NSG DIAGNOSIS:
Fluid volume deficit related to diarrhea
secondary to acute gastroenteritis.

Scientific Basis:
Decreased intravascular, interstitial and/
intracellular fluid. This refers to dehydration,
water loss alone without change in sodium.
NSG GOAL:
After 2-4 hours nursing interventions, the patient will be able to maintain fluid
volume at functional level as evidenced by stable vital signs, moist mucous
membranes & good skin turgor.

OUTCOME CRITERIA:
Independent:
 After 2-4 hours of nursing interventions, patient will experience adequate fluid volume and electrolyte
balance as evidenced by: urine output greater than 30 ml/hr, normal blood pressure, heart rate of 60-100
beats/ min, respiratory rate of 12-20 cycles/min,normal skin turgor.
 Pt. will maintain afebrile state.
 Pt. will initiate rehydration.
 Pt. will increase fluid intake of more than 2 liters.
Dependent:
 Patient will follow medication on time.
Collaborative:
 Patient will eat food prepared for him as advised by dietician.
 NSG INTERVENTION RATIONALE
INDEPENDENT:

• Obtain patient history to • This can help with

ascertain the probable cause making the various
of the fluid disturbance nursing interventions

• Evaluate fluid status in • Most fluids enter the

relation to dietary intake. body through drinking
water in foods & water.

• Monitor temperature . • Febrile states decrease

body fluids through
perspiration.
• Encourage oral hygiene
• Encourage oral intake of
small amounts of fluids
and bland foods.
• Provide oral fluids that are
preferred by the patient
and place it at bedside,
within reach. Ensure that it
is fresh.
• This promotes interest
in drinking, leading to
rehydration
• Eating small amounts
can be helpful because
it is more easily
absorbed.
• Be creative in
providing oral fluids to
promote and
encourage intake.
• Teach interventions to • Client needs to understand
prevent future episodes of the importance of drinking
dehydration/inadequate extra fluid during bouts of
intake. diarrhea.

DEPENDENT:

• Administer medications
and IV fluids as ordered.
 Nursing Care Plan 2
ASSESSMENT

SUBJECTIVE:
– “Sige ug sakit-sakit akong tiyan” as verbalized by the pt.

OBJECTIVE:
– Hyperactive bowel sounds (6 sounds in 20 seconds)
– Abdominal distention
– Facial grimacing and guarding.
– pain sensation at anal area due to irritation from frequent
defecation
– Pain scale of 7 out of 10.
NSG DIAGNOSES:
Pain related to injuring agents (physical –
inflammation of GI tract) secondary to Acute
Gastroenteritis
Scientific Basis:
Acute infectious diarrhea results to increase
frequency and fluid content of stool. The patient
usually has abdominal distention and hyperactive
bowel sounds. Painful spasmodic contraction of the
anus and ineffectual straining may occur with each
defecation.
NSG GOAL:
After 30 mins – 1hour of nursing interventions, the
patient will report relief of pain from a pain scale of
7/10 to a pain scale of 4/10.

OUTCOME CRITERIA:
Independent:
 After 30 mins – 1hour of nursing interventions, the patient will report relief of pain from
scale 7 to 4.
 Pt. will verbalize lesser episodes of pain.
Dependent:
 Patient will follow medication on time.
Collaborative:
 Patient will eat food prepared for him as advised by dietician.
 NSG INTERVENTION RATIONALE

INDEPENDENT:
• Assess pain scale.
• Encourage verbalization of
feelings about pain.
• Serves as part of
baseline data.
• Facilitates timely
intervention.

• Provide comfort measures • Provides non-

(back rub, change of pharmacological pain
position) management.
• Encourage adequate rest
period.
• Instruct patient to report
intense pain as soon as it
begins
DEPENDENT:
• Administer analgesics as
ordered.
• Prevents fatigue.
• Timely intervention is
more likely to be
successful in alleviating
pain.
• Relieves pain
 Nursing Care Plan 3
ASSESSMENT

SUBJECTIVE:
– “Dili ko ganahan mokaon” as verbalized by the pt.

OBJECTIVE:
– Poor muscle tone
– Hyperactive bowel sounds
– Aversion to eating
– Food served remained untouched
NSG DIAGNOSES:
Risk for Imbalanced nutrition: less than body
requirements related to inadequate intake with
nutrients secondary to acute gastroenteritis.

Scientific Basis:
Nutrition is imbalanced to a relative absolute deficiency
of one or more essential nutrients. This may be manifested
as undernutrition.
NSG GOAL:
After 8 hrs of nursing intervention, patient will exhibit
progressive signs of appetite as evidenced by increased
food intake.

OUTCOME CRITERIA:
• Independent:
After 8 hours of student nurse patient intervention ,
patient will brush teeth every after meals, pt will
verbalize satiety of food by evidence of at least
consumption one half cup of rice.
• Dependent:
Patient will follow medication on time.
• Collaborative:
Patient will eat food prepared for him as advised by
dietician.
Patient will cooperate with the S/O and nurse to
determine proper way of selecting nutritional food
 NSG INTERVENTION RATIONALE

INDEPENDENT:
• Provide oral hygiene • Clean mouth can enhance
the taste of food

• Pleasant environment aids

• Serve food in well-
in reducing stress and is
ventilated, more conducive to eating
pleasant surroundings.
• Individual tolerance varies,
depending on stage of
• Avoid/ limit foods that disease and area of bowel
might cause/exacerbate affected.
abdominal cramping and
flatulence
• Encourage bed rest and/ • Decreased metabolic
limit activity needs aids in preventing
caloric depletion and
conserve energy.

DEPENDENT:
• Administer medication as
specified by the doctor.

COLLABORATIVE:
• Coordinate with dietician
• Health teachings to pt and
S.O. on proper nutrition and
hygienic preparation of
food.
 F. Progress and Prognosis

The actual progress and prognosis of the

disease of the patient X can be referred to as
“Fair”. The patient was discharged last July 30,
2009. The main s/sx or the course of illness
had been relieved by medication therapy and
treatment instituted. It was successful but it
was considered as fair because generally, the
prognosis is dependent upon compliance of the
prescribed treatment regimen.
 G. Discharge Planning
MEDICATIONS:
– Follow strictly medication regimen such as oral rehydration solution or as
prescribed by the physician and report immediately of adverse reactions.

EXERCISE:
– Carry out daily activities as tolerated.
– Do activities of daily living as tolerated.

TREATMENT:
– Take medications as scheduled and as prescribed for fast recovery.

HEALTH TEACHING:
– Observe proper personal hygiene to avoid complication; frequent hand
washing is advised.
– Observe proper food preparation and handling to avoid reinfection.
OUT-PATIENT:
– Advise patient to visit for check-up to the doctor for further
follow-up of health status.

DIET:
– Follow religiously the prescribed diet to regain strength and
improve health status; these include BRAT (banana, rice,
apple, tea) diet.

SPIRITUAL:
– Advise family to ask assistance and guidance from the divine
providence for speedy recovery.