IDENTIFICATION OF DATA
PATIENT NAME - Mr.vivek verma
AGE- 24 year
GENDER- male
M.R.NO- 21002863
WARD- MICU
ADDRESS-
EDUCATION-doing graduation
OCCUPATION- student
MARITAL STATUS-unmarried
RELIGION- hindu
DATE OF ADMISSION- 24/8/2023
DIAGNOSIS - diarrhea
CHIFF COMPLAINS-
Patient come with the complain of loose motion 5 to 6 time a day since last 4 days. He was
taking treatment from a doctor in his area. Once take medicine taken relived but again the same
taken place after 4 to 5 hours. He was not satisfied with the treatment so decided to take
treatment from hospital.
PRESENT COMPALAIN-
Treatment for diarrhea
PAST MEDICAL HISTORY-
Taking treatment for loose motion from a doctor of his area.
PRESENT SURGICAL HISTORY-
No significant history
PAST SURGICAL HISTORY-
No significant history
SOCIO- ECONOMIC HISTORY-
Patient is living in pakka house. Electricity facility available. Source of water is tap water. He
also gave history of good sanitation in his house. There is proper satiation facility available.
All are using common washroom.
PERSONAL HISTORY-
DIET
SMOKING
ALCOHOL
BOWEL & BLADDER
FAMILY HISTORY-
Patient belong to middle class family. There are 5 member in her family , patient, his mother, his
father and 2 sister . children are not yet married.
S.NO NAME FO AGE/SEX EDUCATIO OCCUPATION HEALTH
THE N STATUS
FAMILY
MEMBERS
1. RAVINDRA 45Y/M Graduate Teacher Healthy
SINGH
2. PUSHPA 42Y/F 12th passed House wife Healthy
DEVI
3. VIVEK 24Y/M Doing Student Unhealthy
VERMA graduation
4. POOJA 27Y/F Graduate Employee Healthy
5. REETU 23Y/F Graduate student Healthy
FAMILY MEDICAL HISTORY-
There is no significant family medical history of family member
PHYSICAL EXAMINATION
GENERAL APPWARENCE
Look- anxious
Posture- normal
Health- unhealthy
Mourishment- nourished
Consciousness- conscious
Anthropometric measurement
Hight- 150cm
Weight-50kg
BMI- 22.2
Vital sign
Temp- 98*f
Pulse-82 beats/min
Res.-20 breath/min
B.P -130/90 mm of hg
HEAD TO TOE EXAMINATION
Head
Skull- NO nodules or masses
Scalp- Clear
Shape- Normal
Size- normal
Hair- Normally distributed
Eyes
Eyebrows- Evcnly distributed
Eyelashes- Equally distributed
Eyelids- Symmetrical
Vision- Normal
Ears
External Ear- Normal
Symmetry- symmetrical
Hearing- Normal
Nose
Symmetry- symmetrical
Discharge-absent
Mouth
Lips -pink
Teeth-no dislocation
Gums-no retraction
Neck
Lymph node- no enlarge
Movement- normal
Chest-
Symmetry-symmetrical
Chest wall-intact
Abdomen
Inspection-no scars
Palpation-no tenderness,no masses
Percussion-bowel sound
Auscultation- bowel and bladder disturbed
Upper extremities
Symmetry--symmetrical
Movement-normal
Lower extremities
Symmetry--symmetrical
Movement-normal
Medication
Medication name Dose/frequency Route indication Side effect
Tab loperamide 4mg\OD ORAL Chronic diarreal Dry nouth
Traveler’s diarrhea Abdominal discomfort
Rash and itching
Tab pansec 40mg\OD ORAL Erosive Diarrhea
esophagitis Headache
Hypersecretory Dizziness
condition Rash
Inj. Cefixime 250mg\BD IV Bacterial infection Dry nouth
Abdominal discomfort
Rash and itching
DISEASE CONDITION
DIARRHEA
Introduction
Diarrhea is the one of the most common manifestation of illness in infants and
children. It is characterized by on possible change in color of feces in comparison
with the usual of breast feed infant may be several stool a day where as that of is
symptom of variety of condition and it constitute are of the main causes of
morbidity and mortality.
Definition
Diarrhea: an increase in the no. of stool or a decreased in their consistency as a
result of alteration of water and electrolyte transport by the alimentary tract
Causes:
False Food intake
GI infection
Ingestion of poison
Administration of anti-biotics
Emotional disturbance
Laxative abuse
Food allergy
Malabsorbtion
Malnutrition
Inflammation of intestinal tract
Sign and symptoms
Diarrhea refers to watery stools, but it may be accompanied by other symptoms.
These include:
stomach pain
abdominal cramps
bloating
weight loss
fever
body aches
chills
Diarrhea is also a symptom of other conditions, some of which can be serious.
Other possible symptoms are:
Prevention :
Children should be isolated to prevent infection
Excreta should be disinfected and disposed properly.
Contamination should be prevented.
Assessment characteristic of diarrhea should be done properly.
General hygiene should be provided
Comforting the pt is essential dry, clean and comfortable linen should be
provided.
Once loose motion control high calorie, high protein diet should be given to
make up the weight.
The parents should be explained about the above prevention and also about
the importance of hand washing
Explain them about the sign and symptom of diarrhea and dehydration
Explain them about the oral rehydration therapy
Nutritional status should be monitored continuously
Care of the skin is important.
Test & diagnosis-
When diagnosing the cause of diarrhea, a doctor will ask about the person’s
symptoms and:
any current medications they take
their past medical history
their family history
their travel history
any other medical conditions they have
They will also ask:
when the diarrhea started
how frequent the stools are
if blood is present in the stool
if the person has been vomiting
whether the stools are watery or contain mucus or pus
how much stool there is
They will also look for signs of dehydration. Severe dehydration can be fatal if the
person does not receive rehydration therapy immediately.
Test- CBC,LFT,STOOL TEST,
Nursing diagnosis
Loose motion related to disease condition as evidenced by
verbalization.
Anxiety related to disease condition as evidence b by
verbalization.
Malabsorption related to disease condition as evidence by loose
motion.
Risk of infection related to disease condition as evidence b by
observation.
Knowledge deficit related to disease condition as evidence b by
verbalization.
Evaluati
Assessment Goal Intervention Rational Implementation
Nsg diagnosis on
SUBJECTIVE Loose motion To To assess the To make baseline Patient condition Loose
DATA- related to relieve patient’s for care. assessed. motion
Patient says “I disease condition from condition has been
am having loose as evidence by loose To educate to To relive from Pt educated to take relived to
motion verbalization. motion . take fiber diet. motions. fiber diet. much
OB JECTIVE extent.
DATA-
I observed that To record the To inform the
patient is having no.of motion doctor’s and to No. pf motions has
loose motion being passed. see improvement been recorded.
To take To get well soon.
medication on Medication has been
time as take as per doctor’s
prescribed b y prescription.
the doctor.
Evaluati
Assessment Goal Intervention Rational Implementation
Nsg diagnosis on
SUBJECTIVE anxiety related to To To assess the To make baseline Patient condition Anxiety
DATA- disease condition reduce patient’s for care. assessed. has been
Patient says “I as evidence by anxiety. condition reduced .
am very anxious verbalization.
about my To give To support him psychological
disease. psychological mentally. support given to the
OB JECTIVE support to patient.
DATA- patient.
I observed that
patient is having To allow him To make him feel Pt allowed to
anxious. ventilate his relieved. ventilate his feeling.
feeling.
To educate to For proper Pt educate to take
take medication treatment. medication on time
on time as as prescription.
prescribed b y
the doctor.
Evaluati
Assessment Goal Intervention Rational Implementation
Nsg diagnosis on
SUBJECTIVE malabsorption To To assess the To make baseline Patient condition Malabsor
DATA- related to improve patient’s for care. assessed. ption has
Patient says “I disease condition malabsor condition. been
am having loose as evidence by ption. Patient assessed for reduced
motion loose motion To assess for the motion to much
OB JECTIVE the motions of extent.
DATA- the patient. Assessed abdominal
I observed that To make out the discomfort,
patient is having level of care to frequency and
malabsorption Assess for be provided urgency.
abdominal
discomfort Evaluated pattern of
frequency. These defecation.
assessment
Evaluate findings are Asked about
pattern of linked with tolerance of milk
infection. diarrhea and other dairy
product
Ask about
tolerance of Will help in
milk and other treatment. Medication has been
dairy product.. take as per doctor’s
prescription.
HEALTH EDUCATION
The most important treatment for diarrhea is to drink fluids that
contain water, salt, and sugar, such as oral rehydration solution
(ORS). Sports drinks (eg, Gatorade) may be acceptable if you
are not dehydrated and are otherwise healthy.Interventions to
prevent diarrhoea, including safe drinking-water, use of
improved sanitation and hand washing with soap can reduce
disease risk. Diarrhoea should be treated with oral rehydration
solution (ORS), a solution of clean water, sugar and salt.
CONCLUSION
Diarrhea has two major complications: dehydration (which happens
because of frequent or severe Diarrhea) and malabsorption (because of
chronic Diarrhea). Diarrhea can also be an indication of serious
underlying conditions. Through proper treatment and diagnosis, you can
avoid future problems
BIBLIOGRAPHYS
1. K. Park(2007). textbook of preventive and social medicine .(19 th
edition) .Jabalpur. M/s Banarsidas Bhanot publishers.
2.B.T.Basavanthappa.(2008) community health nursing . (2nd edition) newdelhi.
Jaypee brothers medical publishers (p)ltd.
3. mareia Stanhope and Jeanette lanearteei.(2004) community and public health
nursing (sixth edition)Missouri mosby publications.
4.suzanne.c.smelter,brende g.bare.,Janice.c.hinkle and Kerry.h.cheever.(2008)
textbook of medical-surgical nursing vol-2 (11th edition)wolters
kulwar(india)pvt.ltd
