SALVADOR, JHON KELVIN C.

BSN 211

Px: Aguilar, Alfred Carl 7y/o Rm: 332 A Dx: AGE p Viral r/o UTI c some DHN

Cues Nursing Analysis Goals and Nursing Rationale Evaluation

Diagnosis Objectives Interventions

Subjective Cues: Diarrhea Colonization of Goals: Independent:

• “Noong related to Bacterial, Viral, • At the end of • Monitor Vital • To obtain baseline • The client
Tuesday pa infectious Parasitic the shift, the signs data. (Nurse’s was able to
sya nagtatae” processes as pathogens. client is Pocket Guide 11th reestablish
as stated by evidenced by expected to ed., Doenges, and
the client’s increased reestablish Moorhouse, Murr) maintain
mother. peristalsis, and maintain normal
• “Matubig pa frequency Pathogens may normal pattern • Diarrhea in pattern of
rin ang dumi and watery adhere to or of bowel • Note client’s age infant/young child bowel
nya” as stated stools invade the functioning. or older or functioning.
by the client’s epithelium debilitated client
mother. can cause
• “Ngayon araw Objectives: complications of • The client
nakakatatlong • After 5 dehydration and was able to
dumi na sya” Produce minutes of electrolyte identify 2
as stated by enterotoxins or discussion, the imbalance. out of 3
the client’s cytotoxins client will be (Nurse’s Pocket importance
mother. able to identify Guide 11th ed., s of fluid
• “Hindi naman 2 out of 3 Doenges, intake
daw masakit importances of Moorhouse, Murr, within 3
tyan nya ” Infectious fluid intake • Inspect, palpate, pg. 261) minutes.
stated by the process occurs within 3 percuss, and
client’s minutes. auscultate • These are • The client
mother. abdomen; note performed as part was able to
• “Wala naman whether bowel of a physical identify 4
Increase of the • After 5 sounds are out 5
akong examination, or
bowel minutes of frequent proper diets
naaalalang when a patient
movement discussion, the within 3
 kinain nya na frequency, client will be presents with minutes.
hindi maganda loose, watery able to identify abdominal pain or • The client
o madumi” stools, 4 out 5 proper a history that was able to
stated by the dehydration diets within 3 do the
suggests an
client’s minutes. proper
mother. abdominal
• After 5 principle of
• “Malinis minutes of • Identify cause of pathology. hand
naman ang DIARRHEA demonstration diarrhea if (Amerine E, Keirsy washing
bahay namin , the client will possible based M: Managing acute within 3
eh. Siguro be able to do on history (e.g., diarrhea, pg. 64, minutes.
nagkanganyan the proper rotavirus or 2004.)
dun sa labas” principle of norovirus • The client
as stated by hand washing exposure; HIV • Identification of was able to
the client’s within 3 infection; food the underlying demonstrat
mother. minutes. poisoning; cause is important, e proper
• “Mineral water medication because the fluid intake
ang tubig • After 4 hours effect; radiation treatment often of at least 8
namin” as of nursing therapy; protein depends on it. glasses a
stated by the intervention, malnutrition; (Thielman NM, day.
client’s the client will laxative abuse; Guerrant RL:
mother. be able to stress). Clinical practice.
demonstrate Acute infectious • The client
Objectives: proper fluid • Assess stool diarrhea, J Med was able to
• Loose, watery intake of at consistency and 350(1):38, 2004.) follow the
stools, 3x least 8 glasses its influence on
Small
• Hyperactive a day. risk for stool loss.
Several Frequent
bowel sounds
• After 4 hours classification Feedings on
• Vital Signs: • A study of stool
BP – 90/60 of nursing systems for stool consistency found Soft Low
Temp – 36.5 intervention, have been good reliability Fat Diet.
O
C the client will promulgated. when evaluated by
PR – 110 be able to professional
RR – 22 follow the nurses, student
• 20 kgs. Small Frequent nurses, and
Feedings on clients. Word-only
Soft Low Fat descriptors yielded
Diet. equivocal
consistency when
assessed by
subjects as did
tools that
combined words
with illustrations of
various stool
consistencies.
(Bliss DZ, Johnson
• Weigh the client S, Savik K et al:
daily and note Fecal incontinence
decreased in hospitalized
weight. patients who are
acutely ill, Nursing
Research,101,
2000)

• An accurate daily
weight is an
important
indicator of fluid
balance in the
• Give dilute clear body. (Metheny,
fluids as Fluid and
tolerated (e.g., Electrolyte
clear soda, Balance: Nursing
gelatin dessert), Considerations, 4th
serving at Ed., Philadelphia,
lukewarm 2000, Lippincott
temperature. Williams & Wilkins)

• Giving oral fluids

can replace the
fluid loss as
diarrhea usually
 follows
• Monitor and dehydration.
record intake (Metheny, Fluid
and output; note and Electrolyte
oliguria and dark, Balance: Nursing
concentrated Considerations, 4th
urine. Ed., Philadelphia,
2000, Lippincott
Williams & Wilkins)

• These will
determine early
signs of
• Encourage the dehydration.
client to eat (Metheny, Fluid
small, frequent and Electrolyte
meals, to Balance: Nursing
consume foods Considerations, 4th
that are easy to Ed., Philadelphia,
digest (e.g., 2000, Lippincott
bananas, Williams & Wilkins)
crackers,
pretzels, rice, • The use of a BRAT
potatoes, clear diet (bananas,
soups, rice, applesauce,
applesauce), and and toast) with
to avoid milk avoidance of milk
products, foods products (since a
high in fiber, and transient lactase
caffeine (dark deficiency may
sodas, tea, occur) is
coffee, commonly
chocolate). recommended,
although limited
data supports this.
(Thielman NM,
Dependent: Guerrant RL:
• Administer Clinical practice.
antidiarrheals as Acute infectious
prescribed by the diarrhea, J Med
physician. 350(1):38, 2004.)

• Decreases G.I
motility or
peristalsis and
diminishes
• Administer digestive
medications as secretions to
ordered. relieve cramping
and diarrhea.
(Nurse’s Pocket
Guide 11th ed.,
Doenges,
Moorhouse, Murr,
Collaborative: pg. 262)
• Obtain stool
specimens as • To treat infectious
ordered. process, decrease
motility, and/or
absorb water.
(Nurse’s Pocket
Guide 11th ed.,
Doenges,
Moorhouse, Murr,
• Recommend the pg. 263)
parents give the
child oral
rehydration • To either rule out
fluids to drink in or diagnose an
the amounts infectious process
specified by the (e.g., ova and
 physician, parasites, C.
especially during difficile infection,
the first 4 to 6 bacterial cultures).
hours to replace (Nursing Diagnosis
lost fluid. Once Handbook, 8th
the child is Edition, Ackley)
rehydrated, an
orally • Treatment with
administered oral rehydration
maintenance fluids for children
solution should are generally as
be used along effective as
with food. intravenous (IV)
fluids; IV fluids do
not shorten the
• Recommend duration of
parents give gastroenteritis and
children foods are more likely to
with complex cause adverse
carbohydrates, effects than oral
such as potatoes, rehydration
rice, bread, therapy. (Banks,
cereal, yogurt, Meadows,
fruits, and Intravenous fluids
vegetables. The for children with
BRAT diet is gastroenteritis,
often advocated. pg.121, 2005.)
Avoid fatty foods
and foods high in • When a child has
simple sugars diarrhea, dietary
modification
includes avoiding
dairy products,
because viral or
bacterial infections
can cause a
transient lactase
deficiency. Easily
digested food,
such as bananas,
rice, applesauce,
and toast, are also
recommended.
(Amerine E, Keirsy
M, Managing acute
diarrhea, pg. 64,
2004)