Cues/Needs

Nursing
Diagnosis
Subjective data:
Diarrhea
related to
4 na beses siyang
presence of
dumumi sa ngayon
toxins as
tapos matubig, sa ihi
manifested by
naman kakaunti lang
frequent
2-3x as verbalized by elimination of
the mother.
mushy stools.
Objective data:
>Increased
bowel
sounds/perist
alsis
>Frequent mushy
stools
>Changes in
stool color

Rationale
intestinal fluid
output
overwhelms
the absorptive
capacity of the
GI tract
damage to the
villous brush
border of the
intestine,
malabsorption
of intestinal
contents
leading to an
osmotic
diarrhea,
release of
toxins that bind
to specific
enterocyte
receptors
release of
chloride ions
into the
intestinal

Goals and
objectives
After 5
hours of
Nursing
Intervention
the patients
parent/
watcher will:
>Report
reduction in
frequency of
stools,
>return to
more normal
stool
consistency.

Interventions

Rationale

Evaluation

> Observe and

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

> Helps
differentiate
individual
disease and
assesses
severity of
episode.

After 5 hours
of
nursing
intervention
the goal was
partially met.
The patients
watcher
verbalized a
mushy stool
and
less
frequent
of
defecation.

> Identify foods and

fluids that
precipitate diarrhea,
e.g., raw vegetables
and fruits, wholegrain cereals,
condiments,
carbonated drinks,
milk products
>Monitor Intake and
Output. Note
number, character,
and amount of
stools; estimate
insensible fluid
losses, e.g.,
diaphoresis.
Measure urine
specific gravity;
observe for oliguria.
>Observe for
excessively dry skin
and mucous
membranes,
decreased skin
turgor, slowed

>Avoiding
intestinal
irritants
promotes
intestinal rest.

>
Provides
information
about overall
fluid balance,
renal function,
and
bowel
disease control,
as
well as
guidelines for
fluid
replacement.
>

Indicates

lumen, leading
to secretory
diarrhea.

capillary refill.
COLLABORATIVE

excessive fluid
loss/resultant
dehydration

> Administer
parenteral fluids,
blood transfusions
as indicated.

> Monitor
laboratory studies,
e.g., electrolytes
(especially
potassium,
magnesium) and
ABGs (acid-base
balance).
> Administer
medications as
indicated:
Antidiarrheal e.g.,
dipphenoxylate
(Lomotil),
loperamide
(Imodium), anodyne
suppositories
> Electrolytes, e.g.,

> Maintenance
of bowel rest
requires
alternative fluid
replacement to
correct
losses/anemia.
Note: fluids
containing
sodium may be
restricted in
presence of
regional
enteritis.
> Determines
replacement
needs and
effectiveness of
therapy.

potassium
supplement (KCl> Reduces fluid
IV;K-Lyte, Slow-K); losses
from
intestines.

> Electrolytes
are lost in large
amounts,
especially in
bowel with
denuded,
ulcerated areas,
and diarrhea
can also lead to
metabolic
acidosis
through loss of
bicarbonate
(HCO3).