Problem: Diarrhea and Dehydration

Explanation of
Assessment
Problem

Goal and
Objectives

Nursing
Interventions

Rationales

Evaluation

SAMPLE NCP
Subjective data:
basa yung tae
niya, matubig at
mabaho na ang
laman ay kanin
at iba pa niyang
nakain kanina,
as verbalized by
the mother.
His eyes
appear to have
become deeper
and his mouth
and tongue
appears slightly
dry, as
verbalized by
father.
Frequently
requests to
drink water

Objective data:
Dry skin and
mucus
membranes
Sunken
fontanelles
Poor skin turgor
10 bowel
movements in 8
hour shift
Rice watery
yellowish stool
with foul odor

Diarrhea resulted
from ingestion of
food carrying
pathogenic
microorganism that
entered the GI
tract. This invasion
caused activation
of the inflammatory
process that altered
regular absoption
and metabolic
processes.
Increased
peristaltic
movement led to
diarrhea episodes
that led to fluid
loss, thus
dehydration signs
and symptoms.

LTO: After 72
hours of Nursing
Interventions, the
client will exhibit
optimal hydration
status as
manifested by:
- Good skin
turgor
- Moist skin
and mucus
membranes
- Hematocrit
within
normal range
of 0.40- 0.54
STO: After 8 hours
of Nursing
interventions, the
client will exhibit
reduction in fluid
loss as manifested
by:
- Lesser bowel
movement
from 10 per
shift to at
least once
per day
- Elimination
of formed
stools
-

Diagnostic:
1. Monitor vital
sign -observe
for decreased
pulse pressure
first, then
hypotension,
tachycardia,
decreased pulse
volume

2. Review
laboratory
results
hematocrit,
urinalysis and
fecalysis

3. Monitor for
inelastic skin
turgor, thirst,
dry tongue and
mucous
membrane,
longitudinal
tongue furrows,
speech difficulty

Diagnostic:
1. A decreased
pulse pressure is
an earlier
indicator of
shock from
dehydration
than is the
systolic blood
pressure.
Decreased
intravascular
volume results
in hypotension
and decreased
tissue
oxygenation.
2. Increased
hematocrit and
increased urine
specific gravity
are signs of
increasing blood
concentration
usually from
dehydration.
Reviewing
fecalysis may
identify source
of diarrhea and
dehydration.
3. These are signs
of deficient fluid
volume. Since
inelastic skin
turgor, thirst
and dry tongue

amounting to
700 mL per bout
of diarrheal
episode
Laboratory
Result
Blood Test
Hematocrit: 0.55
Fecalysis result
with positive
amoeba
idenitification

Nursing Diagnosis:
Fluid volume deficit
related to excessive
fluid and electrolyte
loss through normal
route.

, dry skin,
sunken eyeballs,
weakness
(upper body)
and confusion.

4. Observe and
record Intake
and output
including: bowel
movement
frequency,
amount,
characteristics
and
precipitating
factors
5. Monitor daily
weight

6. Identify foods
and fluids that
aggravate or
precipitate
diarrhea.
Therapeutic:
Independent
1. Provide fluids

and mucous
membrane are
manifested by
the client upon
admission, it is
important to
check these to
see if there is
significant
improvement in
hydration.
4. This is done to
see if extent of
fluid loss

5. Body weight
changes reflect
changes in body
fluid volume. A
1- pound weight
loss reflects a
fluid loss of
about 500 mL.
6. This is done to
avoid them in
order to avoid a
more severe
case of diarrhea.
Therapeutic:
Independent
1. The oral route is
preferred for
maintaining

2. Provide
prescribed diet
BRACT banana,
rice, crackers,
toast diet ;

3. Provide
positional
changes

4. Rest the bowel

when client is
vomiting or has
diarrhea (e.g.,
restrict food or

fluid balance.
Distributing the
intake over a
24- hour period
accompanied by
snacks and
preferred
beverages
increases the
likelihood that
the patient will
comply with the
prescribed oral
intake.
2. Provides
essential
nutrients and
helps avert
liquid and soft
stools (low in
fiber and
caffeine that
can increase
intestinal
motility)
3. Promotes skin
integrity (e.g.,
monitor areas
for breakdown,
ensure frequent
weight shifting)
becausedeficien
t fluid volume
decreases tissue
oxygenation,
which makes
the skin more

fluid intake
when
appropriate,
decrease intake
of milk
products).

Collaborative
1. Hydrate patient
with Oresol as
ordered by
physician.
2. Administer
Metronidazole
as ordered by
physician.

Educative:
1. Instruct client
and family
about signs of
deficient fluid

vulnerable to
breakdown.
4. Prevents further
inflammation
and irritation of
GI tract. The
most common
cause of
deficient fluid
volume is
gastrointestinal
loss of fluid. At
times, it is
preferable to
allow the
gastrointestinal
system to rest
before resuming
oral intake.
Collaborative
1.Oresol rehydrates
patients and
replenishes lost
electrolytes .
2. Metronidazole
Interacts with DNA
of Entamoeba
histolytica
(causative agent of
Amoebiasis that
caused the diarrhea
of the patient) to
cause strand
breakage and loss
of helical structure
effects that result

volume that
indicate they
should contact
health care
provider.
2. Instruct client
and family the
correct
technique for
hand hygiene
and to always
perform it as
much as
possible.
3. Instruct client
and family
about risks of
eating food not
cooked by them
and drinking
water at
questionable
sources.

in the inhibition of
nucleic acid
synthesis that leads
to cell death.

Educative:
1. In order to not
make the
dehydration
more severe,
immediate
action must be
done upon
seeing signs of
dehydration.
2. This is a safety
measure used to
avoid
microorganisms
to enter the
body.
3. Since diarrhea
caused by water
drank at
questionable
sources and
food eaten that
are cooked
outside the
home are most
likely to cause
diarrhea, it is
important for
the family to
kmow where
should they

drink water and

food that wont
harm their
gastrointestinal
tract for
preventive
measures.

SAMPLE JUSTIFICATION AND PRIOROTIZATION OF PROBLEMS

Identified Problems:

Justification

1. Ineffective airway clearance related to retained secretions In Maslows hierarchy of needs, airway can be considered as a
priority need because airway ensures oxygen delivery to the lungs and tissues in general. This is prioritized because
according to ABC prioritization tool, airway is the foremost need/priority. Airway sustains delivery of oxygen that is very
crucial to life.
2. Fluid volume deficit related to excessive fluid and electrolyte loss through normal route. - This is prioritized as second
because according to ABC prioritization tool, breathing is the second need/priority to be met, furthermore, fluid takes
precedence over other physiologic needs like food and temperature and clothing.
3. Hopelessness related to inadequate support system CONTINUE JUSTIFYING