NURSING CARE PLAN

Cues Nursing Diagnosis Desired Nursing Interventions Rationale Evaluation

Outcome/Criteria
•Changed diaper Diarrhea r/t infectious Short Term:Within 4 Independent 1. Indicating hydration Short Term:After 4
3x with loose and process secondary to hours of nursing 1. Assess for presence of hours of nursing
deformed stools systemic viral infection intervention the patient postural hypotension, intervention the
•Abdominal will be able to tachycardia, skin patient will be able to
distention noted demonstrate appropriate hydration/turgor, condition of demonstrate
upon palpation behavior to assist with mucous membranes 2. To determine amount of output appropriate behavior
•Upon resolution of causative 2. Weigh infant’s diapers and fluid replacement needs to assist with
auscultation, factors (e.g., proper food 3. To monitor Gi motility resolution of causative
hyperactive bowel preparation, or avoidance 3. Assess using abdominal factors (e.g., proper
sounds noted. of irritating foods) movements food preparation, or
•Irritated and 4. To help determine the need for avoidance of irritating
crying. 4. Observe and record the stool additional hydration replacement foods)
•250mg diaper Short Term:Within 4 days characteristic
•Dry mucous of nursing intervention 5. To keep the area dry because
membranes the patient will be able to 5. Assist, as needed, with moisture can adhere skin Short Term:With 4
•Heart rate- reestablish and maintain pericare after each bowel breakdown days of nursing
170bpm normal pattern of bowel movement. intervention the
•Hyperactive functioning. 6. Apply lotion/ointment or 6. To keep the area dry because patient will be able to
bowel sound petroleum jelly as skin barrier, moisture can adhere skin reestablish and
as needed. breakdown maintain normal
7. To keep the are clean and pattern of bowel
7. Provide dry linen, as decrease spread of bacteria functioning.
necessary.
8. To avoid foods/ substances that
Dependent precipitate diarrhea

8. Encourage to follow
prescribed diet (Full
hypoallergenic diet)
9. Adminiter prescribed
medication
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