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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

DIARRHEA Nursing Care Plan

Galima is 58 years old teacher in English and Science of high school students. One day he went to his students birthday party which was held inside a huge cruise ship. The party was so nice and wonderful as he dance, sang, ate and drank a lot. It was a great experience for him and he wanted to do it again in his younger son's birthday party. The day after the party, his head was aching and his having stomach upset and he thought maybe it was because of what he was done in the party last night. Below is a sample of diarrhea nursing care plan of Galima.

ASSESSMENT

Subjective:
"I poop five times this day and my stomach is aching up until now, " as verbalized by the patient.

Objective:
I observed from the patient that his/her mouth is dry and had a poor skin turgor. His/her skin is cold and clammy. (Dry mouth and poor skin turgor is caused by dehydration or low body fluids secondary to diarrhea.) I scaled his/her pain 6/10 and the client's vital signs are taken and noted as follows: Body temperature is 36.2 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 16 cycles per minute and pulse rate of 110 beats per minute. Body temperature, respiratory rate and pulse rate are all normal, while his/her blood pressure is above normal and categorize as pre-hypertension.

DIAGNOSIS

Diarrhea related to five loose liquid stools in a day secondary to stomachache and cold clammy skin. (A cold clammy skin is a cool, moist and usually pale skin caused by cold sweat.)

PLANNING

After 4 hours of nursing intervention, the patient's normal pattern of bowel functioning will be reestablished and maintained.

INTERVENTION 

- Factors associated with diarrhea maybe psychological (anxiety) to Galima, situational such as using laxatives, alcohol abuse, or toxins and physiological such as inflammation, irritation, infectious process, and malabsorption. To assess these factors, ascertain onset and pattern of  Galima's diarrhea, noting whether it is acute or chronic. Note the volume and the frequency of his stool. Also observe for presence, location and characterised of Galima's bowel sounds. And to eliminate causative factors, you can consider the following nursing interventions below:

- Assist Galima in treatment of underlying conditions such as infections, malabsorption syndrome and complication of diarrhea. Therapies can include treatment of fever, pain, and infectious agents.

- In diarrhea, hydration and electrolyte imbalance must be addressed. Administer to 
Galima anti-diarrheal medications, as indicated to decreased his gastrointestinal motility and minimizes his fluid losses. Encourage Galima to oral intake of fluids containing electrolytes, such as juices, bouillon, or commercial preparations, as appropriate.

- To maintain 
Galima's skin integrity, provide him prompt diaper change and gentle cleansing because skin breakdown can occur quickly when diarrhea is present. Apply lotion or ointment to his skin as skin barrier and provide dry linen but expose perineum or buttocks to air.

- To promote return to normal bowel functioning, increased 
Galima fluids intake and return to normal diet as tolerated but avoid intake of irritating fluids. Recommend to Galima foods such as natural fiber, plain natural yogurt to restore normal bowel flora. Administer medications as ordered to treat infectious process, decrease motility, and absorb water. Also provide Galima's privacy during defecation and physiological support as necessary.

- Remember to emphasize importance of handwashing to 
Galima to prevent spread of infectious causes of diarrhea such. Review causative factors and appropriate interventions to prevent recurrence of diarrhea. Review food preparation, emphasizing adequate coming time and proper refrigeration to prevent bacterial growth and contamination. Discuss possibility of dehydration and importance of proper fluid replacement.

EVALUATION

After 4 hours of nursing intervention the patient's normal pattern of bowel functioning was reestablished and maintained.

For more samples of nursing care plan you are free to check it out in our NCP LIST page.

2 comments:

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