Cues Inference Nursing Goal/Plan Intervention/Plan Rationale Evaluation

Diagnosis
Subjective data: intestinal fluid Diarrhea related After 3 days > Observe and > Helps After 3 days of
output to presence of of Nursing record stool differentiate nursing
Intervention frequency, individual disease
6 na beses siyang overwhelms the toxins as the patients characteristics, and assesses intervention the
dumumi sa ngayon absorptive manifested by parent/ amount, and severity of goal was partially
tapos matubig, sa ihi capacity of the frequent watcher will: precipitating episode. met. The
naman kakaunti lang 2- GI tract elimination of factors. patients watcher
>Report >Avoiding
3x as verbalized by mushy stools. reduction in > Identify foods verbalized a
the mother. damage to the frequency of and fluids that intestinal irritants mushy stool and
villous brush stools, precipitate promotes less frequent of
Objective data: diarrhea, e.g., raw intestinal rest. defecation.
border of the >return to vegetables and
intestine, more normal fruits, whole-grain
Increased bowel
sounds/peris stool cereals,
talsis malabsorption of consistency. condiments,
Frequent, and carbonated
intestinal drinks, milk
often severe,
mushy stools contents products
Changes in stool > Provides
color leading to an >Monitor Intake and information about
Output. Note overall fluid
osmotic number, character, balance, renal
diarrhea, and amount of function, and bowel
stools; estimate disease control, as
insensible fluid well as guidelines
release of toxins losses, e.g., for fluid
that bind to diaphoresis. replacement.
Measure urine
specific specific gravity;
enterocyte observe for oliguria. > Indicates
excessive fluid
receptors >Observe for loss/resultant
excessively dry skin dehydration
release of and mucous
membranes,
chloride ions into decreased skin
the intestinal turgor, slowed
capillary refill.
lumen, leading COLLABORATIVE
to secretory > Maintenance of
> Administer bowel rest requires
diarrhea. parenteral fluids, alternative fluid
blood transfusions replacement to
as indicated. correct
losses/anemia.
Note: fluids
containing sodium
may be restricted in
presence of
regional enteritis.
> Monitor laboratory
> Determines
studies, e.g.,
replacement needs
electrolytes
and effectiveness of
(especially
therapy.
potassium,
magnesium) and
ABGs (acid-base
balance).

> Administer > Reduces fluid

medications as losses from
indicated: intestines.
Antidiarrheal e.g.,
dipphenoxylate
(Lomotil),
loperamide
(Imodium), anodyne
suppositories

> Electrolytes, e.g., > Electrolytes are

potassium lost in large
supplement (KCl- amounts, especially
IV;K-Lyte, Slow-K); in bowel with
denuded, ulcerated
areas, and diarrhea
can also lead to
metabolic acidosis
through loss of
bicarbonate
(HCO3).
 Cues Nursing Diagnosis Goal/Plan Intervention/Plan Rationale Evaluation
After COPAR > Determine > Individual may not be After 3 days of
Subjective data: the clients ability physically, emotionally, ornursing
community
will: readiness, and mentally capable at this intervention
Nuay kame aqui barriers to time. the goal was
ustedes onde saka extra learning. met. The
income para na di amun >Have patients
mga needs, nesecita > To determine > Promotes understanding watcher
kame mga livelihood other factors and may enhance verbalized
programs para chene pertinent to the cooperation with regimen understanding
kame onde saka extra learning process. of disease
sen. processes,
>To assess clients and possible
Objective data: motivation. complications
> Reduces spread of
Houses made of light > Provide written bacteria and risk of skin
materials usually its the information or irritation/breakdown,
cause of low financial aid guidelines and self- infection.
learning modules
for client to refer
to as necessary.
> Patients with IBD are at

> Provide active role

risk for colon/rectal
in client in learning cancer, and regular
process. diagnostic evaluations
may be required
 Cues Inference Nursing Goal/Plan Intervention/Plan Rationale Evaluation
Diagnosis
intestinal fluid Hyperthermia After 3 > monitor patient > Temperature of 102F- After 3 days of
Subjective data: output days of temperature 106F (38.9C- 41.1C) nursing
related to Nursing
overwhelms the dehydration as Intervention (degree and suggests acute infectious intervention
tapos ngayon may absorptive the patients pattern); note disease process. Fever the goal was
evidenced by
lagnat siya kaya capacity of the parent/ shaking pattern may aid in met. The
pinupunasan ko siya GI tract increase in body watcher will: chills/profuse diagnosis; e.g., sustained patients
para bumaba ang temperature diaphoresis. or continuous fever watcher
lagnat sabi ng doktor damage to the higher than . curves lasting more than demonstrated
verbalized by the > Demonstrate 24 hour suggest temperature
villous brush normal range.
patients mother. temperature pneumococcal within normal
border of the
within normal pneumonia, scarlet or range and free
intestine,
Objective data: range, and be typhoid fever; remittent from chills.
malabsorption of free of chills. fever (varying only a few
(+) poor skin degrees in either
turgor intestinal
direction) reflects
(+)muscle wasting contents
(+) sunken pulmonary infections;
fontanel intermittent curves or
leading to an
fever that returns to
T-38.1C osmotic normal once in 24-hour
diarrhea, period suggests septic
episode, septic
release of toxins endocarditis, or
that bind to tuberculosis (TB). Chills
specific often precede
enterocyte temperature spikes.
receptors Note: Use of antipyretics
 release of alters fever patterns and
chloride ions may be restricted until
into the diagnosis is made or if
intestinal lumen,
fever remains higher that
leading to
102F (38.9C).
secretory >Monitor
diarrhea. environmental
> Room
temperature;
temperature/number of
Increase cellular limit/add bed linens
blankets should be
metabolism as indicated.
altered to maintain near-
normal body
hyperthermia . > Provide tepid
temperature
sponge baths; avoid
use of alcohol.
> May help reduce fever.
Note: use of ice
water/alcohol may cause
chills, actually elevating
Collaborative
temperature. In addition,
alcohol is very drying to
>Administer
skin
antipyretics as
ordered by >Used to reduce fever by
physician, e.g., its central action on the
acetylsalicylic acid hypothalamus; fever
(ASA) (aspirin), should be controlled in
acetaminophen patients who are
(Tylenol). neutropenic or asplenic.
However, fever may be
benefial in limiting
growth of organisms and
enhancing
autodestruction of
infected cells
> Provide cooling
blanket > Used to reduce fever,
usually higher than 104F-
105F (39.5C-40C), when
brain damage/seizures
can occur
 Cues Inference Nursing Goal/Plan Intervention/Plan Rationale Evaluation
Diagnosis
intestinal fluid output Nutrition, less After 3 days of > Measure infants > for initial data base and to After 3 days of
overwhelms the Nursing height and weight see gain or lose in weight. nursing
than body Intervention the
Objective data: absorptive capacity everyday and compare intervention
requirements patient will: it each day.
of the GI tract the goal was
related to
(+) poor skin partially met.
turgor excessive fluid > Note status of > Inadequate fluid intake
damage to the villous fontanels, production results in dehydration, The patient
(+)muscle loss and
wasting brush border of the of mucus, and skin turgor, and number of did not fully
(+) sunken malsabsorption number of wet wet diapers per day. gain weight
intestine, manifested by depressed
fontanel as manifested diapers per day. necessary for
fontanels, reduced urine
malabsorption of by poor skin output poor skin turgor, and her age..
Wt.= 1.8 kg(<2500 dryness of mucous
g) SGA intestinal contents turgor, muscle
membranes. Note: Cases of
wasting, hypernatremic dehydration
leading to an osmotic sunken have been associated with
diarrhea, fontanel and use of cows
milk feedings.
release of toxins that Wt.= 1.8
> Illness, infection, or
bind to specific kg(<2500 g) marginal diet may affect
SGA > Obtain 24-hr dietary mothers ability to nourish
enterocyte receptors
recall in lactating the infant adequately.
mother. Note Factual information may
release of chloride
presence of illness, help correct myths/ faulty
ions into the infection, or dietary beliefs resulting in
intestinal lumen, inadequacies. Provide inadvertent or deliberate
leading to secretory dietary teaching, as food restrictions.
diarrhea. appropriate, noting Supplementing diet with
cultural/religious brewers yeast improves
Increase cellular practices. Identify milk production significantly
adequate sources of more than simply adding
metabolism
calcium and protein; similar nutrients.
suggest
hyperthermia .
supplementing
maternal diet with > Skim milk contains about
brewers yeast as half the number of calories
appropriate. in breast or commercial
 formulas; may not meet the
>Encourage continued infants energy needs; and
use of formula for first may cause deficiencies in
12 mo. of life. iron, vitamin C, and fatty
acids. Use of whole milk in
Discourage
the first 12 mo may place
substitution of skim or the infant at risk for iron,
whole cows milk. vitamin C, and copper
deficiencies.
> Altered elimination
> Determine color, pattern may suggest
frequency, problem with digestion and
consistency, and odor absorption. Foul-smelling
of stool. stool suggests parasitic
infection. Diarrhea may
reflect milk intolerance or
ingestion of cathartics in
lactating mother.
Collaborative > Alternative formulas
relieve symptoms
> Provide information
associated with cows milk
as needed about
intolerance.
prescribed
alternatives to milk,
such as soy milk
formulas or
hydrolyzed protein
and amino acid
> FTT infants who are
mixtures. breastfed may benefit from
having the mother
bottlefeed breast until the
> Instruct in addition infant is gaining weight
to human milk appropriately on a
fortifiers(HMF), as consistent basis. Note: The
indicated, to milk morning and evening
supplemented with feeding may be from the
extra calories breast breast in order to support
the maternal breastfeeding
milk, which is experience.
pumped and stored
 for feedings.
Cues Inference Nursing Goal/Plan Intervention/Plan Rationale Evaluation
Diagnosis
intestinal fluid Risk for After 3 Independent > Minimizes introduction of After 3 days of
output days of > Wash hands, and bacteria and spread of nursing
infection Nursing
Objective data: overwhelms the instruct parents to do so infection. intervention
related to Intervention before handling infant..
absorptive the patient the goal was
thin,
(+) poor skin capacity of the will: met. The
turgor permeable > Observe newborn for > These abnormalities may
GI tract skin abnormalities (e.g., be signs of infection.(Refer patient is free
(+)muscle wasting skin and lack
(+) sunken blisters, petechiae, to CP: The Neonate at 2 from
fontanel damage to the of normal > Be free of pustules, plethora, or Hours to 2 Days of Age; ND: infection. The
signs of Infection, risk for.) parent
villous brush intestinal flora pallor).
Wt.= 1.8 kg(<2500 g) border of the infection . day, or less often, as identified
SGA indicated, and using mild individual risk
intestine, antibacterial soap. factors and
Recommend sponge appropriate
malabsorption of bathing until umbilical
And the parents actions.
intestinal cord detaches.
will: > Guidelines for parents
contents > Discuss skin care,
including bathing every help them protect fragile
> Identify other skin of newborn from
leading to an excessive drying or damage.
individual risk
osmotic Note: Foreskin of
factors and uncircumcised penis should
diarrhea,
appropriate not be retracted for
cleaning; rather, external
release of toxins actions washing and rinsing are
that bind to sufficient.
specific > The umbilical cord is an
> Inspect umbilical cord. open site susceptible to
enterocyte
infection. It should show
receptors evidence of beginning
dryness, and no bleeding,
release of exudate, odor, or oozing
chloride ions should be present by the
2nd day of life.
into the
intestinal lumen,
leading to > Review appropriate > Reduces likelihood of
secretory cord care. Ensure that infection; promotes drying.
diarrhea. clothes and diaper do Cord should fall off by the
not cover stump. Provide 2nd wk of life. Note:
information regarding the Knowing it does not hurt
normal progression of the baby when the cord
cord resolution. detaches provides
reassurance to parents.

> Complete healing of

> Inspect site of circumcision does not occur
circumcision, if until 710 days after the
performed. Note undue procedure.
bleeding, oozing, or
swelling. (Refer to CP:
Circumcision.)
> Infection in the neonate
> Observe for/discuss may be manifested by
signs of infection. Assess pallor, irritability, lethargy,
axillary temperature as poor feeding, vomiting,
indicated. diarrhea, loose stools,
oliguria, or temperature
instability. Parental
awareness promotes early
recognition and increases
likelihood of prompt
medical attention.

> Because the neonate is

more susceptible when
> Recommend avoiding exposed to some infections,
contact with family visitors should be screened.
members or visitors who Note: Communicability is
have infections or have usually highest during the
recently been exposed to incubation period of many
infectious processes. diseases.