Kapiolani Community College

Associate Degree Nursing Program

Nurs320 Nursing Care Plan
Student Name: Van Mai
Nursing Diagnosis: Diarrhea

Date of Care: 03/17/16

Date Submitted: 03/28/16

Related to: Clostridium difficile infection

As manifested by: frequency of liquid, pink tinged stools.
Scientific Rationale: Patient has diarrhea due to bacterial infection as a result of antibiotic side effect
Outcomes (measurable)

Interventions

Rationale

Evaluation

Short Term

1. Assess bowel sound, frequency and

types of stools

1. Hyperactive bowel sound, increased

frequency and liquid stools are common
finding in diarrhea. Instructed caregiver
to write diary of time and frequency,
stored soil diaper to assess.

1. Patient bowel sound was normal

active. Patient had one soft-formed
stools.

2. Assess hydration (I&O, skin turgor,

mucous membranes) and electrolytes
status

2. Diarrhea can lead to dehydration lead

to decrease UOP and skin turgor,
tenting skin, and dry mucous
membranes. Diarrhea cane cause
metabolic acidosis, leading to
electrolytes.

2. Patient OP intake increased, good

skin turgor, moist mucous membranes.
His UOP was 6ml/hr.

Patient stops having diarrhea, maintains

fluid and electrolyte balance and skin
intact as evidenced by reduce frequency
and liquid stools, good skin turgor and
absence of redness and irritation in skin,
no skin breakdown by the end of the
shift.

Long Term
Patient passes soft formed stools once
a day every other day in 3 days

3. Assess perianal skin condition.

Instruct caregiver to provide perianal
care after each bowel movement and
apply powder and protective barrier
creams as needed.
4. Instruct caregiver to encourage fluid
intake and administer IV fluid and
replace electrolytes as ordered.

3. Frequent moisture and enzymes in

stools may cause irritation and damage
to the skin. Powder and barrier creams
protect the skin from moisture and
corrosive enzymes, bacteria.
4. Loss of fluid in stools can cause
dehydration. Electrolytes imbalance can
be treated with oral or IV electrolyte
solution.

3. Dad demonstrated appropriate

perianal care after each bowel
movement. He applied powder and
protective barrier creams to diaper area.
The redness reduced. Patient cried upon
urination and diaper changing may
indicate skin irritation.
4. Dad reported patient improved oral
intake. UOP was adequate and
electrolyte values were within acceptable
range. Discontinued IV fluid on 03/17/16
morning. Patient had pedialytes and

5. Administer antibiotic on time as

ordered. Administer antidiarrheal drug
and probiotics as ordered. Monitor signs
effects.

5. Antibiotic is prescribed to treat

bacterial infection. Administer on time to
maintain therapeutic serum level to be
effective and prevent resistant
development. Antidiarrheal drug
decrease gastrointestinal motility.
Probiotics reestablish normal flora in the
intestine.

6. Anticipate contact precaution and

wash hand with soap and water after
contact patient every time. Instruct
caregiver and family practice hand
hygiene.

6. Contact precaution and good hand

hygiene prevent transmission of
microorganism to others.

7. Educate caregiver to avoid feeding

client with fluid or food that stimulate or
irritate bowel such as too hot, too cold
fluid or food, high seasoning and fatty,
frying foods. Encourage in take of boil,
bake, and broil foods.

7. Appropriate dietary can slow the

passage of stool in the colon and reduce
or stop diarrhea.

formula feeding.
5) 60mg Flagyl antibiotic was prescribed
4 times a day per oral. Patient
developed large red papular rash
generalized though out the body.
Antihistamine PRN was prescribed for
itching.
6. Health care team practiced
appropriate contact precaution and hand
hygiene. Dad practice practiced hand
hygiene after changing diaper every
time.
7. Patient appetite increased. Patient
was fed with formula and table foods.
Dad indicated understanding appropriate
dietary needed and stated would be
easy to apply because patient is not a
picky eater.

Reference:
Ball, J., Bindler, R., & Cowen, K. (2012). Principles of pediatric nursing: Caring for children (5th ed.). Boston: Pearso
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.). Philadelphia, PA: Elsevier.