Czarina C. Dofredo Mhay V. Baldonaza Nursing Diagnosis:      Acute pain related irritation of the bowel wall.

Fluid volume deficient related to active fluid loss. Activity intolerance related to fluid volume deficient. Altered Nutrition Risk for altered skin integrity

Czarina C. Dofredo Mhay V. Baldonaza

Nursing Care Plan

ASSESSMENT S> Masakit yung tiyan ko. Pain scale of 8/10 O> with guarding behavior >grimace noted >irritable at times >easy fatigability >Abdominal Pain >Weak in appearance >Limited range of motion >Reduced interaction with people >sleep disturbances Diagnosis: Acute pain related irritation of the bowel wall. Scientific Explanation: Gastroenteritis is the inflammation of the stomach and intestinal tract that primarily affects the small PLANNING  Within 30 mins 1 hour of rendering proper nursing interventions the patient will be able to report pain is relieved / controlled by the pain scale of 8/10 to 4/10. IMPLEMENTATION  Perform comprehensive assessment of pain scale, include location, quality, severity and duration.  Note the client s locus of control. RATIONALE  To assess etiology/ precipitating contributory factors. EXPECTED OUTCOME  After 30 mins 1 hour of rendering proper nursing interventions the patient will be able to report pain is relieved / controlled by the pain scale of 8/10 to 4/10.

 Individuals with external locus of control may take a little or no responsibility for pain management.  Observations may or may not be congruent with verbal reports indicating need for further evaluation.  To evaluate client s response to pain.

 Observe non-verbal cues seen by the patient.

 Ascertain client s knowledge of and expectations about pain management.  Review client s previous experiences with pain and methods found either helpful or unhelpful for pain control in the past.

 To know what proper implementations to be rendered to the client.

bowel. One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the body s immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen. (Joyce M. Black, 2008)

 Work with client to prevent pain. Instruct the client to report as soon as it begins.  Provide a quiet environment, calm activities to the patient.  Provide comfort measures.

 Timely interventions are more likely to be successful in alleviating pain.  To promote relaxation.

 To provide nonpharmacologic pain management.  To alleviate attention and comfort to relief pain

 Encourage diversional activities

 Instruct the client the use of relaxation exercises such as deep breathing.  Instruct client to avoid foods such as milk and chocolate.  Indentify way of minimizing the pain such as; firm mattress, good body mechanism.  Administer analgesics to maintain acceptable level of pain if not contraindicated and as prescribed.  Monitor effectiveness of pain medications

 Deep breathing exercises may reduce pain sensation.

 Milk and chocolate increases gastric motility.  Helps relieve pain.

 To decrease pain.

 To promote timely intervention/ revision of plan of care

ASSESSMENT S> Tubig yung tae ko. O> elimination of watery stool at 3-5 times a day >dry lips >dry skin >pale and weak in appearance >skin turgor of 3-4 seconds >Vomiting

PLANNING  Within 3-4 hours of rendering proper nursing interventions the client will be able to replace fluid volume loss.

IMPLEMENTATION  Note possible diagnosis that may create a fluid volume deficient  Monitor Input & Output

RATIONALE  To assess causative/ precipitating factors  To ensure accurate fluid status  To evaluate degree of fluid deficit  To evaluate degree of dehydration.  To know what food to be given by the preference of the client.  To prevent dehydration & maintain hydration status  For proper fluid replacement.

 Assess skin turgor regularly

EXPECTED OUTCOME  After 3-4 hours of rendering proper nursing interventions the client will be able to replace fluid volume loss.

 Note physical signs of dehydration.  Note client s preferences regarding fluids and foods with high fluid content.  Maintain adequate hydration and increase fluid intake  Keep fluid within the client s reach and encourage frequent intake as appropriate.

>abdominal cramping >nausea >fatigue >dry mucous

membrane Diagnosis: Fluid volume deficient related to active fluid loss Scientific Explanation: Acute gastroenteritis is an inflammation of the stomach and

 Instruct client to have oral care.

 To prevent injury to the mucosal lining and to prevent from dryness  For pharmacological management.

 Administer medications as prescribed by the physician.

intestinal tract that primarily affects the small bowel. The universal manifestation of gastroenteritis is diarrhea which occurs in varying intensity, depending on the organism involved and the health status of the client. Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. (Joyce M. Black, 2008)

 Administer Intravenous fluids as prescribed  Restrict solid food intake, as indicated

 Young individuals are quickly affected by fluid volume deficit  To allow for bowel rest and to reduced intestinal workload

 Discuss factors related to occurrence of dehydration.  Recommend restriction of caffeine as indicated  Don t allow patient to sit or stand up quickly as long as circulation is compromise.

 To have knowledge about the disease and know the prevention.  Caffeine has diuretic. To prevent more fluid loss.  To avoid orthostatic hypotension and possible syncope.