NURSING ANALYSIS/HEALTH GOAL AND

CUES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS IMPLICATION OBJECTIVES

INTERACTION Diarrhea Inatake of causative After 4 hours of  Observe and record stool  Helps differentiate After 4 hours of
“Nagtatae siya 4 related to agents nursing frequency, individual disease and nursing
days na” As infectious ↓ interventions, the characteristics, amount assesses severity of interventions, the
verbalized by the processes as Irritation of the client will report client was able to
and precipitating factors. episode.
mother. stomach
manifested by reduction in report reduction in
↓
OBSERVATION
passage of Inflammation of the
frequency of  Promote bed rest.  Rest decreases frequency of
loose watery stomach passage of stool. intestinal motility and passage of stool.
 WBC count stool ↓ reduces metabolic rate.
10.4 Increase GI motility
↓  Identify foods and fluids  Avoiding intestinal
 Lymphocytes
Diarrrhea that precipitate diarrhea. irritants promotes
0.167
 Hyperactive intestinal rest.
bowel
movements  Restart oral fluid intake  Provides colon rest by
gradually. Offer clear omitting or decreasing
liquids hourly, and avoid stimulus of foods or
fluids.

 Encourage to eat foods  Fruits that are stool

like banana and apple. former.

 Avoid foods that are oily,  Foods that may

spicy and caffeine. precipitate gastric
cramping.

 Administer antidiarrheals  Decreases G.I motility

as prescribed by the or peristalsis and
physician. diminishes digestive
secretions to relieve
cramping and diarrhea.
 NURSING ANALYSIS/HEALTH GOAL AND
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES

OBSERVATION Nutrition, less intestinal fluid After 3 days of > Measured height and > for initial data base and After 3 days of
than body output overwhelms Nursing Intervention weight everyday and to see gain or lose in nursing
(+) poor skin requirements the absorptive the patient will: isplay compared it each day. weight. intervention the
turgor related to capacity of the GI physical growth and goal was partially
(+)muscle excessive fluid tract Gain weigth > Note status of fontanels, > Inadequate fluid intake met. The patient
wasting
(+) sunken loss and ↓ appropriate for age production of mucus, and results in dehydration,
skin turgor, and number of
did not fully gain
fontanel malsabsorption damage to the and developmental number of wet diapers per wet diapers per day. weight necessary
as manifested villous brush stage. day. for her age
Wt.= 1.8 by poor skin border of the
kg(<2500 g) SGA turgor, muscle intestine, >Encourage continued use > Skim milk contains about half
wasting, ↓ of formula for first 12 mo. the number of calories in breast
sunken malabsorption of of life. Discourage or commercial formulas;
fontanel and intestinal contents, substitution of skim or
Wt.= 1.8 vitamins and whole cow’s milk.
kg(<2500 g) electrolytes > Determine color,
SGA frequency, consistency, > Altered elimination
and odor of stool. pattern may suggest
problem with digestion
and absorption.

> FTT infants who are

> Instruct in addition to
human milk fortifiers(HMF),
as indicated, to milk
supplemented with extra
calories breast milk, which
is
pumped and stored for
feedings.
breastfed may benefit
from having the mother
bottlefeed breast until the
infant is gaining weight
appropriately on a
consistent basis. Note:
The morning and evening
feeding may be from the
breast in order to support
the maternal
breastfeeding experience.
 NURSING GOAL AND
CUES INFERENCE NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES

INTERACTION Knowledge Disease Process After 8 hours > Determine the mother’s >Establishes knowledge After 3 days of
“akala ko normal deficient related ↓ of Nursing perception of disease base and provides some nursing
lang namagtae Presence of Signs Intervention the
to unfamiliarity of patient’s parent/ process. insight into individual intervention the
siya, limang araw the condition and and symptoms watcher will: learning needs goal was met.
bago namin siya ↓
information The patient’s
dinala sa ospital”. Ignore signs and
misinterpretation >Verbalize > Review disease process, >Accurate knowledge base watcher
As verbalized by symptoms
the mother. . ↓ understanding of cause/effect relationship of provides opportunity for the verbalized
Aggravations of the disease factors that precipitate mother to make informed understanding of
OBSERVATION conditions processes, symptoms, and identify decisions/choices about disease
The statement ↓ possible ways to reduce contributing future and control of processes, and
supports the idea Knowledge Deficit complications factors. Encourage chronic disease. Although possible
that the parents questions. most others know about complications
have deficient their own disease process,
information they may have outdated
regarding the information or
illness of their
misconceptions.
child.
> Review medications,
purpose, frequency, > Promotes understanding
dosage, and possible side and may enhance
effects. cooperation with regimen

>Stress importance of good > Reduces spread of

skin care, e.g., proper bacteria and risk of skin
handwashing techniques irritation/breakdown,
and perineal skin care. infection.

> Patients with IBD are at

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