Baseline Data Carl Danielle Mandig

BN3H
Name of Patient:
Age: 50y/o
Sex: Male
Diagnosis: Acute Gastro Enteritis
Attending Physician: Dr. C.
Chief Complaint: Loose Watery Stools

Nursing Care Plan

ASSESSMENT NURSING RATIONALE DESIRED NURSING JUSTIFICATION EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
Objective:
. Food irritates GI Short Term: Independent: After 8 hours of nursing
• Increased After 8 hours of intervention my client
peristalsis nursing was able to:
Abdominal cramping intervention my
• Frequent client will be able 1. Observe and record 1. Helps differentiate 1. GOAL MET
watery stools to: stool frequency, individual disease Client was able to state
Cramping characteristics, amount & assesses severity of characteristic,
•Abdominal precipitating factors episode frequency and amount
pain of stool
Increased Motility
• V/S taken as 2. GOAL MET
2. Promote bed rest 2. Rest decreases
follows: intestinal motility and Patient has decrease
Urgency his intestinal bed rest
Source: Nanda reduces metabolic rate
T: 36.6 11th Edition
P: 80 Authors: 3. Urge to defecate 3. GOAL PARTIALLY
R: 18 - Marilynn Doenges Loose Watery Stool 3. Provide bedside may occur w/out MET
Bp: 110/80 - Mary Moorhouse commode warning and Comply with all his
-Alice Murr uncontrollable, medications and all the
increasing risk of procedures done to
 incontinence or tells if him.
facilitates are not close
 . at hand

Strengths/Welln
ess:
4. Identify foods & fluids
 Emotiona
that precipitate diarrhea
l support
4. Avoiding intestinal
from his wife irritants promotes
& daughter. 5. Restart oral fluid intake intestinal rest
 His gradually. Offer clear
strong belief liquids hourly, and avoid 5. Provides colon rest
& faith in cold fluids by omitting or
God. decreasing stimulus of
foods or fluids gradual
consumption of liquids
may prevent cramping
and recurrence of
diarrhea
Collaborative:
 Administer Anti-
diarrheals as  Decreases GI
prescribed by the motility and
physician diminishes digestive
secretions to relieve
cramping & diarrhea