Patients name: Age: 1year old Gender: Male

Medical Diagnosis: LBM, vomiting, fever

DATE J U L Y 12, 2 0 1 1

CUES Subjective: Sukad gahapon basabasa iyang tae as verbalized by the mother Obective:

NEED E L I M I N A T I O N P A T T E R N

NURSING DIAGNOSIS Diarrhea related to presence of toxins as manifested by frequent elimination of mushy stools. As evidenced by: Passage of loose, unformed stools pathogens cause tissue damage and inflammation by releasing endotoxins that stimulate the mucosal lining of the intestine resulting in the greater secretion of water and electrolytes into the intestinal lumen. The active secretions of chloride and bicarbonate ions are the small bowel leads to the inhibition of sodium re-absorption.

OBJECTIVE/GOAL After the rotation and nursing intervention the patient will: >Report reduction in frequency of stools, >return to more normal stool consistency.

INTERVENTIONS > Observe and record stool frequency, characteristics, amount, and precipitating factors. R: Helps differentiate individual disease and assesses severity of episode. > Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products. R: Avoiding intestinal irritants promotes intestinal rest. >Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria. R: Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. > Avoid foods that are oily, spicy and caffeine R: Foods that may precipitate gastric cramping

EVALUATION After the rotation and nursing intervention the goal was met. The patients mother verbalized a formation of stool and less frequent of defecation.

Frequent watery
stools. Increased bowel sounds. Irritated and uncomfortable. Changed diaper 3x with loose and deformed stools. Vomiting T: 36.9 degree celcius CR: 122 RR: 27

>Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.