Date and Time

Cues Subjective: Cge lang siya ug tae, mao gidala namo dria as verbalized by the mother Objective: y y y Hyperactive bowel sounds (36) Audible borborygmi Passage of loose liquid watery stools for more than 3 times

Need

Nursing Diagnosis Diarrhea

Objectives of Care Within 1-2 days of nursing interventions, my patient will reestablish and maintain normal pattern of bowel functioning as evidenced by: a.)passage of semisolid stools

Nursing Interventions 1. Assess general condition and vital signs -For baseline data 2. Auscultate abdomen -For presence, location, and characteristics of bowel sounds 3. Discuss the different causative factors and rationale for treatment regimen - For parents education and prvent recurrence 4. Weigh infants diaper -to determine amount of output and fluid replacement needs

Evaluation

GOAL MET

E L I M I N A T I O N P A T T E R N

Gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus (straining on defecation), and borborygmi (hyperactive bowel sounds). Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowel results in diarrhea. (Joyce M. Black, 2008)

After 1-2 days of nursing interventions, the patient will reestablish and maintain normal pattern of bowel functioning as evidenced by: a.)passage of semisolid stools

5. Encourage mother to breastfeed the child -For fluid replacement And for better immunity, since breastmilk reduces the incidence of gastroenteritis. 6. Emphasize to the parents the importance of hand washing -To prevent spread of infectious diseases 7. Administer antidiarrheal medications as ordered -to decrease gastrointestinal motility and minimize fluid losses 8. Provide prompt diaper change and gentle cleansing -because skin

breakdown can occur quickly when diarrhea is present 9.Discuss possible changes in infant formula -Diarrhea may be result of/ aggravated by intolerance to specific formula

Date and Time

Cues Subjective:(none) Objective:

Need

Nursing Diagnosis

Objectives of Care

Nursing Interventions 1. Monitor and record VS -To obtain base line data. Increase in temperature manifest there is an increase utilization of fluids in the body.

Evaluation

y y y y

passage of loose watery stool weakness decreased urine output fever

N U T R I T I O N A L M E T A B O L I C P A T T E R N

Deficient fluid volume related to excessive losses through normal routes as evidenced by frequent passage of loose watery stool

Within 1-2 days span of nursing Interventions, the patient will maintain fluid volume at functional level as evidenced by: a.) well hydrated, intake is equal as output b.) maintain normal skin turgor c.) absence of loose watery stool.

GOAL MET After1-2 days span of nursing Interventions, the patient will maintain fluid volume at functional level as evidenced by: a.) well hydrated, intake is equal as output b.) maintain normal skin turgor c.) absence of loose watery stool.

Rationale: Acute gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The universal manifestation of gastroenteritis is diarrhea which occurs in varying intensity, depending on the organism involved and the health status of the client. Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. (Joyce M. Black, 2008)

2. Monitor Input & Output balance -to ensure accurate picture of fluid status

3. Maintain adequate hydration, increase fluid intake. To prevent dehydration & maintain hydration status 4. Administer Intravenous fluids as prescribed To deliver fluids accurately and at

desired rates 5. Determine effects of age. Very young and extremely elderly individuals are quickly affected by fluid volume deficit 6. Discuss individual risk factors/ potential problems and specific interventions To prevent or limit occurrence of fluid deficit.