NURSING CARE PLAN
ASSESSMENT
Subjective: “Madalas akong dumumi ngayon kaysa kahapon” as verbalized by patient. Objective: • • Increased peristalsis. Frequent watery stools. Abdominal pain. V/S taken as follows: T: 36.6 P: 80 R: 18 Bp: 110/90 •
DIAGNOSIS
Diarrhea related to presence of toxins. •
INFERENCE
Diarrhea is the passage of loose and watery stools (more than 3 bowel movements per day) often associated with gassiness, bloating, and abdominal pain. It may also be accompanied by nausea, vomiting, and fever. Diarrhea results to loss of body fluids and salts leading to dehydration of varying severity. Severe dehydration may cause death especially in children •
PLANNING
INTERVENTION
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RATIONALE
Helps differentiate individual disease and assesses severity of episode. Rest decreases intestinal motility and reduces metabolic rate. Urge to defecate may occur without warning and uncontrollable, increasing risk of incontinence or falls if facilities are not close at hand. Avoiding intestinal irritants promotes intestinal rest. Provides colon rest by omitting or decreasing stimulus of foods or fluids. Gradual consumption of liquids may prevent cramping and
EVALUATION
• After 4 hours of nursing intervention s, the patient was able to report reduction in frequency of stools.
Independent: After 4 hours • Observe and of nursing record stool interventions, frequency, the patient characteristics, will report amount and reduction in precipitating frequency of factors. stools. • Promote bed rest.
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Provide bedside commode.
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Identify foods and fluids that precipitate diarrhea. Restart oral fluid intake gradually. Offer clear liquids hourly, and avoid cold fluids.
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Encourage to eat foods like banana and apple. Avoid foods that are oily, spicy and • caffeine. •
recurrence of diarrhea. Cold fluids can increase intestinal motility. Fruits that are stool former. Foods that may precipitate gastric cramping.
Collaborative: • Administer antidiarrheals as prescribed by the physician.
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Decreases G.I motility or peristalsis and diminishes digestive secretions to relieve cramping and diarrhea.