Cues Subjective data: 4 na beses siyang dumumi sa ngayon tapos matubig, sa ihi naman kakaunti lang 2-3x as verbalized

by the mother. Objective data: Changes in stool color

Nursing Diagnosis Diarrhea related to presence of toxins as manifested by frequent elimination of mushy stools.

Inference The intestinal fluid output overwhelms the absorptive capacity of the GI tract thus gives 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 enterocytes receptors that releases of chloride ions into the intestinal lumen, leading to secretory diarrhea.

Goal/Plan After Nursing Intervention the patient s parent/ watcher will: >Report reduction in frequency of stools, >return to more normal stool consistency.

Intervention/Plan > Observe and record stool frequency, characteristics, amount, and precipitating factors. > Identify foods and fluids that precipitate diarrhea

Rationale > Helps differentiate individual disease and assesses severity of episode. >Avoiding irritants intestinal rest. intestinal promotes

Evaluation

>Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses,

> Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. > Indicates excessive fluid loss/resultant dehydration

>Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. COLLABORATIVE > Administer parenteral fluids.

> Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. > Determines replacement needs and effectiveness of therapy.

> Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).

Subjective data: tapos ngayon may lagnat siya kaya pinupunasan ko siya para bumaba ang lagnat sabi ng doktor verbalized by the patient s mother. Objective data: (+) sunken eye T-37.9C Hyperthermia related to dehydration as evidenced by increase in body temperature higher than normal range.

After Nursing Intervention the patient s parent/ watcher will: > Demonstrate temperature within normal range, and be free of chills.

> monitor patient temperature (degree and pattern); note shaking chills/profuse diaphoresis.

> Temperature of 102F106F (38.9C41.1C) suggests acute infectious disease process. Fever pattern may aid in diagnosis

>Monitor environmental > Room temperature; limit/add bed temperature/number of linens as indicated. blankets should be altered to maintain near-normal body temperature > Provide tepid sponge > May help reduce fever. baths; avoid use of alcohol. Note: use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin Collaborative >Administer antipyretics as ordered by physician, e.g., acetylsalicylic acid (ASA) (aspirin), acetaminophen (Tylenol). >Used to reduce fever by its central action on the hypothalamus; fever should be controlled in patients who are neutropenic or asplenic. > Used to reduce fever, usually higher than 104F105F (39.5C-40C), when brain damage/seizures can occur.

> Provide cooling blanket

Subjective: Knowledge deficient regarding condition, The mother stated that prognosis, treatment, selfthey don t give any care, and discharge needs medication to their child, as related to unfamiliarity akala ko normal lang namagtae siya, limang araw with resources and information bago namin siya dinala sa misinterpretation. ospital . After Nursing Intervention the patient s parent/ watcher will: >Verbalize understanding of disease processes, possible complications. > Determine the mother s perception of disease process. >Establishes knowledge base and provides some insight into individual learning needs >Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. > Promotes understanding and may enhance cooperation with regimen

> Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions. > Review medications, purpose, frequency, dosage, and possible side effects. > Stress importance of good skin care, e.g., proper handwashing techniques and perineal skin care.

> Reduces spread of bacteria and risk of skin irritation/breakdown, infection.

> Emphasize need for long- > Patients with IBD are at term follow-up and risk for colon/rectal cancer, and regular diagnostic periodic reevaluation. evaluations may be required