Cues Inference Nursing Goal/Plan Intervention/ Rationale Evaluation

Diagnosis Plan
Subjective data: intestinal Diarrhea After 3 > Observe > Helps After 3 days
fluid output related to days of and record differentiate of nursing
“6 na beses siyang overwhelms presence of Nursing stool individual intervention
Interventio frequency, disease and
dumumi sa the toxins as n the characteristics assesses the goal was
ngayon tapos absorptive manifested patient’s , amount, and severity of partially met.
matubig, sa ihi capacity of by frequent parent/ precipitating episode. The patient’s
naman kakaunti the GI tract elimination of watcher factors. watcher
lang 2-3x” as mushy stools. will: >Avoiding verbalized a
verbalized by the damage to > Identify intestinal mushy stool
>Report foods and
mother. the villous reduction in fluids that irritants and less
brush border frequency precipitate promotes frequent of
Objective data: of stools, diarrhea, e.g., intestinal rest. defecation.
of the
raw
Increased intestine, >return to vegetables
bowel more and fruits,
sounds/pe malabsorptio normal whole-grain
ristalsis n of intestinal stool cereals,
Frequent, and consistency condiments,
often contents . carbonated
severe, drinks, milk > Provides
mushy leading to an products information about
stools overall fluid
osmotic balance, renal
Changes in diarrhea, >Monitor Intake and
function, and bowel
stool color Output. Note
number, character, disease control, as
release of and amount of well as guidelines
stools; estimate for fluid
toxins that replacement.
insensible fluid
bind to losses, e.g.,
specific diaphoresis.
> Indicates
Measure urine
enterocyte specific gravity; excessive fluid
receptors observe for oliguria. loss/resultant
dehydration

release of >Observe for

excessively dry skin
chloride ions and mucous
into the membranes,
 intestinal decreased skin
turgor, slowed > Maintenance of
lumen, capillary refill. bowel rest requires
leading to COLLABORATIVE alternative fluid
secretory replacement to
> Administer correct
diarrhea. parenteral fluids, losses/anemia.
blood transfusions Note: fluids
as indicated. containing sodium
may be restricted in
presence of
regional enteritis.

> Determines
replacement needs
and effectiveness of
> Monitor therapy.
laboratory studies,
e.g., electrolytes
(especially
potassium,
magnesium) and
ABGs (acid-base
> Reduces fluid
balance).
losses from
intestines.
> Administer
medications as
indicated:
Antidiarrheal e.g.,
dipphenoxylate
(Lomotil),
loperamide
(Imodium), anodyne > Electrolytes are
suppositories lost in large
amounts, especially
> Electrolytes, e.g., in bowel with
potassium denuded, ulcerated
supplement (KCl- areas, and diarrhea
IV;K-Lyte, Slow-K); can also lead to
metabolic acidosis
through loss of
bicarbonate
(HCO3).
 Cues Inference Nursing Goal/Plan Intervention/ Rationale Evaluatio
Diagnosis Plan n
intestinal Knowledge After 8 > Determine >Establishes After 3
Subjective data: fluid output deficient hours of the mother’s knowledge base and days of
overwhelms Nursing perception of provides some nursing
regarding Interventi
The mother stated the on the disease insight into interventio
condition,
that they don’t absorptive patient’s process. individual learning n the goal
give any capacity of prognosis, needs was met.
parent/
medication to their the GI tract treatment, watcher > Review >Precipitating/aggra The
child, “akala ko self-care, and will: disease vating factors are patient’s
normal lang damage to discharge process, individual; therefore, watcher
namagtae siya, the villous needs as cause/effect the mother needs to verbalized
limang araw bago >Verbalize relationship of be aware of what understand
brush border related to
namin siya dinala understandi factors that foods, fluids, and ing of
of the unfamiliarity
sa ospital”. The ng of precipitate lifestyle factors can disease
statement intestine, with resources symptoms, and precipitate processes,
disease
supports the idea and identify ways symptoms. Accurate and
malabsorptio processes,
that the parents information to reduce knowledge base possible
n of intestinal possible
have deficient misinterpretati contributing provides opportunity complicatio
contents complication
information on. factors. for the mother to ns
regarding the s. Encourage make informed
illness of their leading to an questions. decisions/choices
child. osmotic about future and
diarrhea, control of chronic
disease. Although
release of most others know
toxins that about their own
bind to disease process,
specific they may have
outdated information
enterocyte
or misconceptions.
receptors >Review
medications, > Promotes
release of purpose, understanding and
chloride ions frequency, may enhance
into the dosage, and cooperation with
intestinal possible side regimen
lumen, effects.
leading to
secretory
diarrhea. > Stress
importance of > Reduces spread of
good skin care, bacteria and risk of
e.g., proper skin
handwashing irritation/breakdown,
techniques and infection.
perineal skin
care.
.
> Emphasize > Patients with IBD
need for long- are at risk for
term follow-up colon/rectal cancer,
and periodic and regular
reevaluation. diagnostic
evaluations may be
required
 Cues
Cues Inference
Inference Nursing
Nursing Goal/Plan Intervention/P
Intervention/Plan Rationale
Rationale Evaluatio
Evaluatio
Diagnosis
Diagnosis lan nn
intestinal
intestinal
fluid Hyperthermia
Nutrition, After
After
33days > > monitor > Temperature of After
Measure > for initial data base After 3 3
Subjective data: fluid
output output related
less thanto ofdays
Nursing
of infant’s height
patient and to see gain
102F-106F or losedays
(38.9C- days of of
Objective overwhelms
overwhelms the body Intervention
Nursing and weight
temperature in weight. suggests nursing
41.1C) nursing
dehydration the
Interventi
patient everyday and
“tapos ngayon
data: absorptive
the will:
on the (degree and acute infectious interventio
interventio
as evidenced
requirement compare it each
may lagnat siya capacity absorptive
of the GI patient’s pattern); note disease process. n nthe thegoal
goal
byrelated
s increaseto in day.
(+)pinupunasan
kaya poor capacity
tract of parent/ shaking Fever pattern may was
was met.
> Inadequate fluid
skin
ko siya para the GI tract body
excessive watcher chills/profuse
turgor > Note status ofaidintake in results
diagnosis;
in The
partially
bumaba ang damage to the temperature
fluid loss will: diaphoresis. e.g., sustained
dehydration, or patient’s
met. The
(+)muscle fontanels,
lagnatwastin
sabi ng damage
villous brush to higher
and than . production ofcontinuous
skin turgor, andfever watcher
patient did
doktor” number of wet diapers
g verbalized border the villous
of the normal range.
malsabsorpt mucus, and curves lasting more demonstrat not fully
by(+)
the patient’s > number of wetthan per day.24 manifested
hour edgain weight
brush border ion as
intestine, by depressed
sunken
mother. Demonstrate diapers per day. suggest temperatur
necessary
of the manifested fontanels, reduced
fontan temperature pneumococcal
malabsorption
intestine, of urine output poor skin for within
e her
el
Objective data: by poor skin pneumonia, scarlet normal
age..
intestinal within turgor, and dryness of
turgor, or mucous
typhoid fever; range and
membranes.
Wt.= 1.8 malabsorptio
contents normal
(+) poor skin muscle Note:
remittent Cases of fever free from
kg(<2500
turgorg) n of intestinal wasting, range, and hypernatremic
(varying only a few chills.
SGA
(+)muscle leading to an
contents be free of dehydration have
sunken degrees in either
been associated with
wasting osmotic diarrhea, chills.
(+) sunken direction)
use of cow’sreflects
leading to an fontanel and pulmonary
milk feedings.
fontanel
release of toxins Wt.= 1.8
osmotic > Obtain 24-hrinfections;
thatdiarrhea,
bind to kg(<2500 g) > Illness, infection, or
T-38.1°C dietary recall inintermittent curves
lactating mother.or marginal diet may
specific SGA fever mother’s
that returns
affect ability
release of Note presence ofto normal once in
enterocyte to nourish the infant
illness, infection,
toxins that
receptors 24-hour
adequately. period Factual
or dietary
bind to inadequacies.
suggests
information may septic help
release of
specific Provide dietary episode,
correct myths/ septic
faulty
beliefs resulting or in
chloride ions
enterocyte into teaching, asendocarditis,
inadvertent
tuberculosis (TB). or
the intestinal appropriate,
receptors noting deliberate
Chills often precede food
lumen, leading to restrictions.
secretory cultural/religious temperature spikes.
release of Supplementing diet
diarrhea. practices. IdentifyNote: Use of
chloride ions with brewer’s yeast
adequate sourcesantipyretics alters
of calcium and improves
into the milk
Increase cellular >Monitor production
fever patterns and
intestinal protein; suggest
environmental
metabolism maysignificantly
be restricted more
lumen, supplementing
temperature; than simply adding
leading to maternal diet withuntil diagnosis is
hyperthermia limit/add bed as similar nutrients.
secretory . brewer’s yeast
linens made or if fever
appropriate. as
diarrhea. indicated. remains higher that
> Skim milk contains
>Encourage 102F (38.9C).
Increase about half the number
Provide tepid
> continued use of of calories in breast or
cellular formula baths;
sponge for first> commercial
Room formulas;
metabolism 12 mo.
avoid useof oflife.temperature/numbe
may not meet the
Discourage
alcohol. r of blankets
infant’s should
energy needs;
hyperthermia substitution ofbeand may cause
altered to
skim or whole deficiencies in iron,