NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Sumasakit and tiyan ko at madalas akong dumumi” (I have been having severe diarrhea and abdominal pain) as DIAGNOSIS ♦ Risk for deficient fluid volume related to excessive losses through frequent diarrhea. INFERENCE ♦ Amoebiasis is a infectious disease caused by the parasite Entamoeba histolytica. It is a parasitic infection of the large intestine and characterized by non specific diarrhea with loose, semi formed, foul smelling stools, or dysentery with mucous, traces of blood and small quantities of stools passed repeatedly. Often there is an ineffectual urge to defecate again and again, with very little stool actually being passed. There is much flatulence with PLANNING After 8 hours of nursing interventions, the patient will maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output. INTERVENTION INDEPENDENT: ♦ Monitor intake and output, character, and amount of stools; estimate insensible fluid losses. Measure urine specific gravity and observe for oliguria. RATIONALE ♦ Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. ♦ Hypotension (including postural), tachycardia, fever can indicate response to or effect of fluid loss. ♦ Indicates excessive fluid loss or resultant of dehydration. EVALUATION After 8 hours of nursing interventions, the patient was able to maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output. verbalized by the patient. OBJECTIVE: ♦ Restlessness ♦ Irritability ♦ Facial grimace ♦ Dry skin ♦ V/S taken as follows: T: 37.4 P: 79 R: 19 BP: 110/70 ♦ Assess vital signs (BP, pulse, temperature). ♦ Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. ♦ Weigh daily. ♦ Indicator of overall fluid and nutritional status. abdominal cramps. In severe cases, the liver and other organs may get affected, causing specific conditions related to organ, e.g., hepatitis, cysts, abscess, etc. The most common symptoms of amoebiasis are diarrhea (which may contain blood), stomach cramps and fever. ♦ Maintain oral restrictions, bed rest and avoidance of exertion. ♦ Colon is placed at rest for healing and to decrease intestinal fluid losses. ♦ Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk for hemorrhage. ♦ Excessive intestinal loss may lead to electrolyte imbalance. ♦ Maintenance of bowel rest requires alternative fluid replacement to correct losses. ♦ To reduces fluid losses in the intestine and to prevent further spread of the bacteria. ♦ Observe for overt bleeding and test stool daily for occult blood. ♦ Note generalized muscle weakness or cardiac dysrhythmias. COLLABORATIVE: ♦ Administer parenteral fluids as indicated. ♦ Administer medications as indicated: Antidiarrheal and antibiotics.
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