Nursing Care Plan

Diarrhea
Assessment

Subjective
Apat na beses
na akong
dumudumi as
"verbalized by
the patient"
Objective
-Loose bowel
movement
with yellowish
watery stool
minimum of
thrice a day.
-Increase
bowel sounds/
peristalsis.
-Nausea and
Vomiting
-Abdominal
cramping

Nursing
Diagnos
is
Diarrhea
related
to
infectiou
s
processe
s

Background
Knowledge

Planning

Result from
Infectious(vir
al, bacteria
or parasitic)

Within 8
hours of
nursing
interventions,
the patient
will report
reduction in
frequency of
stools and
return to
more normal
stool
consistency

Increase
absorption of
fluid by the
intestinal
mucosa

Interventions

Rationale

Evaluation

- Observe and
record stool
frequency,
characteristics,
amount, and
precipitating
factors.

-Helps
differentiate
individual disease
and assesses
severity of
episode.

- Promote bed rest

and
provide bedside
commode.

- Rest decreases
intestinal motility
and reduces
the metabolic
rate when
infection or
hemorrhage is a
complication.

After 8 hours of
nursing
interventions,
the client was
be able to
report
reduction in
frequency of
stools and
returned to
more normal
stool
consistency

Hyper
motility of
the intestine

DIARRHEA

- Remove stool
promptly.
Provide room
deodorizers.
- Identify foods
and fluids that
precipitate

- Reduces noxious
odors to avoid
undue client
embarrassment.

diarrhea, such as
raw vegetables
and fruits, wholegrain cereals,
condiments,
carbonated drinks,
and milk products.
- Restart oral fluid
intake gradually.
Offer clear liquids
hourly and avoid
cold fluids.

- Provide
opportunity to
vent frustrations
related to disease
process.

-Observe for fever,

tachycardia,
lethargy,
leukocytosis,

- Avoiding
intestinal irritants
promotes
intestinal rest.

- Provides colon
rest by omitting
or decreasing the
stimulus of foods
and fluids.
- Presence of
disease with
unknown cause
that is difficult to
cure and that
may require
surgical
intervention can
lead to stress
reactions that
may aggravate
condition.

decreased serum
protein, anxiety,
and prostration.

- Administer
medications, as
indicated:
Antidiarrheals,
such as
diphenoxylate
(Lomotil),
loperamide
(Imodium), and
anodyne
suppositories.

- May signify that

toxic megacolon
or perforation and
peritonitis are
imminent or have
occurred,
necessitating
immediate
medical
intervention.
- Decreases GI
motility or
propulsion
(peristalsis) and
diminishes
digestive
secretions to
relieve cramping
and diarrhea.

Deficient fluid volume

Assessment

Nursing
Diagnosis

Subjective
Halos
sampung
beses akong
dumumi at
apat na beses
na nagsuka,
as verbalized
by the patient.

Objective

Deficient fluid
volume
related to
excessive
losses through
normal routes
as evidenced
by frequent
passage of
loose watery
stool and

Background
Knowledge
Rapid
propulsion of
intestinal
contents
through the
small bowels
may lead to a
serious fluid
volume deficit.
The body
would want to
expel the
foreign

Planning
Short term
Within 4
hours of
nursing
interventions,
the patient will
report
understanding
of causative
factors for
fluid volume
deficit

Intervention
s
1. Place
patient in
comfortable
position

2. Administer
PLR 1L as
prescribed

Rationale
1. To make the
patient relax

2.To prevent
peaks and
valleys in fluid
level

3. To ensure

Evaluation
Short term
After 4 hours
of nursing
interventions,
the patient
reported
understanding
of causative
factors for
fluid volume
deficit

abdominal
cramping

dehydratio
n

nausea

fatigue

weakness

dry mucous
membrane

confusion

vomiting

objective as
much as
possible thus
it doesnt
undergo its
normal
speed, with
that, the
digestive
system organs
are not able to
absorb the
excess fluids
that are
usually
absorbed by
the body.

Long Term
Long Term
Within 3 days
of nursing
interventions,
the patient will
maintain fluid
volume at
functional
level as
evidenced by
being well
hydrated,
intake is equal
as output, and
normal skin
turgor

3. Monitor
input and
output
balance

4. Maintain
adequate
hydration,
increase fluid
intake

5. Provide oral
as well as eye
care

accurate
picture of fluid
status

4. To correct
losses and
maintain
hydration
status

5. To prevent
injury from
dryness

6. To prevent
fatigue
6. Encourage
bed rest
7. To reduce
pressure on
fragile skin
7. Change

After 3 days of
nursing
interventions,
the patient
maintained
fluid volume at
functional
level as
evidenced by
being well
hydrated,
intake was
equal as
output, and
normal skin
turgor

position every
2 hours

and tissues

8. To limit
gastric and
intestinal
losses
8. Administer
Metoclopramid
e and
Omeprazole
40 g OD as
prescribed

9. Keep siderails up

10. Discuss
factors related
to occurrence
and ways to
prevent
dehydration

9. To avoid
falls since the
patient is
experiencing
weakness,
fatigue and
confusion
10. To avoid
recurrence of
condition

11. To promote
wellness

11. Identify
and instruct in
ways to meet
specific fluid
needs

Acute Pain
Assessment
Subjective
Mahapdi ang
sikmura ko, as
verbalized by
the patient.
Objective

Verbalizati
on of pain

Nursing
Diagnosis
Acute pain
related to
gastric
irritation as
evidenced by
pain scale of
6/10

Background
Knowledge
Gastric
irritation

Release of
cytokine and
prostaglandin

Increase in
vascular
permeability

Planning
Within 1 hour
of nursing
interventions,
the patient will
report a
decrease of
pain

Intervention
s
1 Place
patient in
supine
position
2

Encourage
patient to
do deep
breathing
exercise

Rationale
1

To make
the patient
comfortabl
e

To reduce
sensation
of pain

Evaluation
After 1 hour of
nursing
interventions,
the patient
reported a
decrease of
pain from a
pain scale of
6/10 to 3/10

with a pain
scale of
6/10
Appears
weak
Limited
range of
motion
Restlessne
ss
Impaired
thought
process
Reduced
interaction
with
people

Pain in the
abdomen

Limit
environme
ntal stimuli
such as
noise

Instruct the
relative to
massage
the area
where pain
is elicited if
not
contraindic
ated

Encourage
doing
diversional
activities,
such as
visualizatio
n,
verbalizatio
n of
feelings or
listening to
music

Excessive
environme
ntal stimuli
can
contribute
to feeling
of
increasing
pain

To lessen or
alleviate
pain

To distract
patients
attention
from pain

To reduce
pain and
promote
relief or
comfort

7
Change
position
every 2
hours

To avoid
bed sores

Provide
cool
environme
nt

To make
the patient
feel more
relax

To promote
patients
safety

Provide
adequate
rest

Keep siderails up

10 Review
ways to
lessen
pain,
including
techniques
such as
therapeutic
touch,
biofeedbac

10 Part of
pain
manageme
nt

k, selfhypnosis
and
relaxation
skills
11 Identify
specific
signs and
symptoms
and
changes in
pain
characteris
tics
requiring
medical
follow-up

11 To promote
timely
interventio
n

Medications
DRUG

GENERIC
NAME:
Omeprazo
le

BRAND
NAME:
Losec,Prilo
sec

CLASSIFIC
ATION
gastrointesti
nal
agent; prot
on pump
inhibitor

DOSAGE

40g IV OD

ACTION

INDICATION

CONTRA
INDICATION

ADVERSE
EFFECT

An
antisecretory
compound that
is a gastric acid
pump inhibitor.
Suppresses
gastric acid
secretion by
inhibiting the
H+, K+-ATPase
enzyme system
[the acid
(proton H+)
pump] in the
parietal cells.

Duodenal and
gastric ulcer.
Gastroesopha
geal reflux
disease
including
severe
erosive
esophagitis
(4 to 8 wk
treatment).
Long-term
treatment of
pathologic
hypersecreto
ry conditions
such as
ZollingerEllison
syndrome,
multiple
endocrine
adenomas,
and systemic

Long-term
use for
gastroesopha
geal reflux
disease,
duodenal
ulcers;
lactation.

CNS:Headach
e, dizziness,
fatigue.
GI:Diarrhea,
abdominal
pain, nausea,
mild transient
increases in
liver function
tests.
Urogenital:H
ematuria,
proteinuria.
Skin:Rash.

NURSING
INTERVENTIO
N

Lab
tests:
Monitor
urinalysis
for
hematuria
and
proteinuri
a. Periodic
liver
function
tests with
prolonged
use.

mastocytosis.
In
combination
with
clarithromyci
n to treat
duodenal
ulcers
associated
with
Helicobacter
pylori.

DRUG

GENERIC
NAME:
Dobutamin
e

BRAND
NAME:
Dobutamin
e
Hydrochlori
de

CLASSIFIC
ATION
Inotropic
agent

DOSAGE

ACTION

INDICATION

CONTRA
INDICATION

Dobutamine
drops 2 ampule

Dobutamine is
an inotropic
agent whose
primary
activity is the
stimulation of
beta receptors
of the heart
while
producing
comparatively
mild
chronotropic,
hypertensive,
arrhythmogeni

-Severe
cardiac
failure
secondary to
AMI or
cardiomyopat
hy.

Idiopathic
hypertrophic
subaortic
stenosis;
hypersensitivi
ty to any
component of
the product;
dobutamine
with dextrose
should not be
administered
simultaneousl
y with blood
through the

-Cardiogenic
shock.
-Septic
shock.
-Congestive

ADVERSE
EFFECT

HeartIncreased
heart rate
and blood
pressure,
chest pain,
palpitation.
LocalInflammation
of vein.
Miscellaneo
us- Nausea,
vomiting,
headache,

NURSING
INTERVENTIO
N
Ideally monitor
BP
continuously.
PA catheter
often desirable.
-Patient must
be on cardiac
monitor.
- ECG, BP, and
hourly urine
measures must
be
continuously
monitored
while PAWP

c and
vasodialative
effects.
Causes an
increase in
cardiac output
(C.O) usually
not associated
with a marked
increase in
heart rate,
while the
stroke volume
is usually
increased.

cardiac
failure.
-Acute
pulmonary
oedema

same infusion
set because
of the
possibility of
pseudoagglut
ination of red
cells.

anxiety,
fatigue and
shortness of
breath

CONTRA
INDICATION

ADVERSE
EFFECT

Potentially
FatalHeart
diseases.

Systemic
vascular
resistance is
usually
decreased due
to stimulation
of beta 2
receptors
which
contributes to
the increased
C.O.

DRUG

CLASSIFICATION

DOSAGE

ACTION

INDICATION

and C.O should

be monitored
wherever
possible.
- Dobutamine
is chemically
stable for 24 /
24 and should
be changed
every 24/24.
- Dobutamine
can be
administered
by a peripheral
line.
- Dobutamine
must always be
administered
via a
volumetric
infusion pump.

NURSING
INTERVENTIO
N

GENERIC
NAME:
Paracetam
ol

BRAND
NAME:
Biogesic,
Panadol,
Tylenol

Nonnarcotic
analgesic, A
ntipyretic

Per Orem:
500mg q4h for
temp. above
37.8

-Decreases
fever by a
hypothalamic
effect leading
to sweating
and
vasodilation
-Inhibits
pyrogen effect
on the
hypothalamicheat-regulating
centers
-Inhibits CNS
prostaglandin
synthesis with
minimal effects
on peripheral
prostaglandin
synthesis
-Does not
cause
ulceration of
the GI tract
and causes no
anticoagulant
action.

-Control of
pain due to
headache,
earache,
dysmenorrhe
a, arthralgia,
myalgia,
musculoskele
tal pain,
arthritis,
immunization
s, teething,
tonsillectomy
-TO reduce
fever in viral
and bacterial
infections

-Renal
Insufficiency

-Minimal GI
upset.

-Anemia

-Methemo
Globinemia
-Hemolytic
Anemia
-Neutropenia
Thrombocyto
pe
Nia
-Pancytopenia
-Leukopenia

-As a substitute for

aspirin in
upper GI
disease,
bleeding
disorders
clients in
anticoagulant
therapy and
gouty
arthritis

-Urticaria
-Liver
Damage

-Do not exceed

4gm/24hr. in
adults and
75mg/kg/day in
children.
-Do not take for
>5days for
pain in
children, 10
days for pain in
adults, or more
than 3 days for
fever in adults.
-ExtendedRelease tablets
are not to be
chewed.
-Monitor CBC,
liver and renal
functions.
-Assess for
fecal occult
blood and
nephritis.

DRUG
GENERIC
NAME:
Metoclopra
mide
BRAND
NAME
Clopra,
Emex ,
Maxeran ,
Maxolon,
Reglan:

CLASSIFICATION
gastrointesti
nal agent;
prokinetic
agent (gi
stimulant);
autonomic
nervous
system
agent;
direct-acting
cholinergic
(parasympat
homimetic);
antiemetic

DOSAGE
q8 PRN

ACTION

INDICATION

Potent central
dopamine
receptor
antagonist.
Structurally
related to
procainamide
but has little
antiarrhythmic
or anesthetic
activity. Exact
mechanism of
action not clear
but appears to
sensitize GI
smooth muscle
to effects of
acetylcholine by
direct action.

Management of
diabetic gastric
stasis
(gastroparesis);
to prevent
nausea and
vomiting
associated with
emetogenic
cancer
chemotherapy
(e.g., cisplatin,
dacarbazine);
to facilitate
intubation of
small bowel;
symptomatic
treatment of
gastroesophag
eal reflux.

CONTRA
INDICATION
Sensitivity or
intolerance to
metoclopramide
; allergy to
sulfiting agents;
history of
seizure
disorders;
concurrent use
of drugs that
can cause
extrapyramidal
symptoms;
pheochromocyt
oma;
mechanical GI
obstruction or
perforation;
history of breast
cancer. Safety
during
pregnancy
(category B) or
lactation is not
established.

ADVERSE
EFFECT
CNS:
Restlessne
ss
,
drowsiness
,
fatigue,
insomnia
dizziness,
anxiety
CV:
tansient
hypertensi
on
GI:
nausea
and
diarrhea

NURSING
INTERVENTION
Report
immediately the
onset of
restlessness,
involuntary
movements,
facial grimacing,
rigidity, or
tremors.
Extrapyramidal
symptoms are
most likely to
occur in children,
young adults,
and the older
adult and with
high-dose
treatment of
vomiting
associated with
cancer
chemotherapy.
Symptoms can
take months to
regress.
Be aware that
during early
treatment period,
serum

aldosterone may
be elevated;
after prolonged
administration
periods, it
returns to
pretreatment
level.

DRUG
GENERIC
NAME:
piperacillin
and
tazobacta
m

BRAND
NAME:
Zosyn

CLASSIFI
CATION
Antibiotic

DOSAGE

ACTION

4.5LMS
Then 2.75
LM q8hr

Inhibits
bacterial cell
wall
mucopeptide
synthesis

INDICATION
indicated for
the treatment
of patients with
moderate to
severe
infections
caused by
piperacillinresistant,
piperacillin/taz
obactamsuscep
tible, lactamase
producing
strains of the
designated
microorganism
s.

CONTRA
INDICATION
contraindicated
in patients with
a history of
allergic
reactions to any
of the
penicillins,
cephalosporins,
or -lactamase
inhibitors.

ADVERSE
EFFECT
signs of
an
allergic
reaction:
hives;
difficulty
breathing;
swelling of
your face,
lips,
tongue, or
throat.

NURSING
INTERVENTION
Obtain history of
hypersensitivity
to penicillins,
cephalosporins,
or other drugs
prior to
administration.
Lab tests: C&S
prior to first dose
of the drug; start
drug pending
results. Monitor
hematologic
status with
prolonged
therapy (Hct and

Hgb, CBC with

differential and
platelet count).
Monitor patient
carefully during
the first 30 min
after initiation of
the infusion for
signs of
hypersensitivity
(see Appendix F).