NURSING CARE PLAN
Nursing Diagnosis/ Analysis Goal and Objectives Intervention Rationale Evaluation
Cues
Diarrhea r/t infectious Scientific: Goal: Independent: After 4 days of nursing
process secondary to Passage of loose, After 4 days of nursing Restrict solid food To allow for bowel interventions, the
Acute Gastroenteritis unformed stools interventions, the intake, as rest/reduced intestinal patient reestablished
pathogens cause patient will reestablish indicated workload and maintained
Subjective: tissue damage and and maintain normal normal pattern of
The mother stated inflammation by pattern of bowel To avoid foods/ bowel functioning.
“simula palang releasing endotoxins functioning. Provide for substances that
nung na admit that stimulate the changes in dietary precipitate diarrhea After 1 hour of
kami dito nung mucosal lining of the Objectives: intake discussion, the
lunes eh nagtatae intestine resulting in After 1 hour of parent verbalized
na talaga siya” the greater secretion discussion, the Limit caffeine and It stimulates gastric understanding
She also added: of water and parent will high fiber foods; motility causative factor
“naawa na nga ako electrolytes into the verbalize avoid milk and and rationale for
sa kanya kasi intestinal lumen. The understanding fruits, as treatment
maya’t maya ay active secretions of causative factor appropriate regimen.
nagpapalit kami ng chloride and and rationale for After 1 hour of
diaper, baka nga bicarbonate ions are treatment Indicating hydration discussion, the
magka-irritation the small bowel leads regimen. Assess for parent
siya sap wet dahil to the inhibition of After 1 hour of presence of demonstrated
dun” sodium re-absorption. discussion, the postural appropriate
“Umiiyak siya To balance the excess parent will hypotension, behavior to assist
minsan at sodium, large amounts demonstrate tachycardia, skin with resolution of
nagcocomplain of protein rich foods appropriate hydration/turgor, causative factors
siya na masakit fluids are secreted in behavior to assist condition of (e.g., proper food
tiyan niya” the bowel’s ability to with resolution of mucous preparation, or
Objective: reabsorb the fluid and causative factors membranes avoidance of
Changed diaper 3x leading to diarrhea. (e.g., proper food To determine amount irritating foods)
with loose and preparation, or Weigh infant’s of output and fluid
deformed stools Situational: avoidance of diapers replacement needs
Abdominal As for the patient, the irritating foods)
distention noted causative factor of her
upon palpation diarrhea is her disease Encourage oral
Upon (Acute Gastroenteritis) intake of fluids
auscultation, containing
hyperactive bowel electrolytes, such
sounds noted. as juices, bouillon,
Irritated and or commercial
crying. preparation as
appropriate.
Assist, as needed,
with pericare after
each bowel
movement. Because skin
Provide prompt breakdown can occur
diaper change and quickly when diarrhea
gentle cleansing is present.
Apply
lotion/ointment or
petroleum jelly as
skin barrier, as
needed.
Provide dry linen,
as necessary.
Expose perineum/ To keep the area dry
buttocks to air; because moisture can
use heat lamp adhere skin
with caustion, if breakdown
needed.
To promote return to
normal bowel
functioning
Increase oral fluid
intake and return
to normal diet, as
tolerated.
Encourage
nonirritating
liquids.
Discuss possible Diarrhea maybe result
change in infant of aggravated by
formula. intolerance to specific
formula.
Recommend To restore normal
products such as flora
natural fiber, plain
natural yogurt,
Lactinex.
Promote wellness
Review causative
factors and
appropriate To prevent diarrhea
interventions. from recurring
Evaluate/identify
individual stress
factors and coping
behavior.
Review food
preparation,
emphasizing
adequate cooking To prevent bacterial
time and proper growth/
refrigeration/stora contamination
ge.
Emphasize the
importance of
hand washing. To prevent spread
infectious causes of
Dependent: diarrhea such as C.
Assist in defficile or S. aureus
treatment of
underlying
conditions (e.g., Therapies can include
infections, treatment of fever,
malabsorption pain, and infectious
syndrome, and toxic agents,
cancer) and rehydration, and oral
complications of feeding, etc.
diarrhea.
Review laboratory
studies for
abnormalities.
Administer enteral
and IV fluids as
indicated.
Administer anti-
diarrheal To decrease
medications, as gastrointestinal
indicated motility and minimize
fluid losses.
Administer
medications, as To treat infectious
ordered. process, decrease
motility, and/or absorb
water.
