9/10/2016

NursingCarePlanfor"InflammatoryBowelDisease"

www.hackafile.blogspot.com
hackafile

NURSINGDIAGNOSIS:FluidVolume,riskfordeficient
Riskfactorsmayinclude
Excessivelossesthroughnormalroutes(severefrequentdiarrhea,vomiting)
Hypermetabolicstate(inflammation,fever)
Restrictedintake(nausea/anorexia)
Possiblyevidencedby
[Notapplicablepresenceofsignsandsymptomsestablishesan

actual diagnosis.]

DESIREDOUTCOMES/EVALUATIONCRITERIAPATIENTWILL:
Hydration(NOC)
Maintainadequatefluidvolumeasevidencedbymoistmucousmembranes,goodskinturgor,andcapillary
refillstablevitalsignsbalancedI&Owithurineofnormalconcentration/amount.

ACTIONS/INTERVENTIONS

RATIONALE

Fluid/ElectrolyteManagement(NIC)

Independent
MonitorI&O.Notenumber,character,andamountof
stoolsestimateinsensiblefluidlosses,e.g.,diaphoresis.
Measureurinespecificgravityobserveforoliguria.

Providesinformationaboutoverallfluidbalance,renal
function,andboweldiseasecontrol,aswellasguidelines
forfluidreplacement.

Assessvitalsigns(BP,pulse,temperature).

Hypotension(includingpostural),tachycardia,fevercan
indicateresponsetoand/oreffectoffluidloss.

Observeforexcessivelydryskinandmucousmembranes,
decreasedskinturgor,slowedcapillaryrefill.

Indicatesexcessivefluidloss/resultantdehydration.

ACTIONS/INTERVENTIONS

RATIONALE

Fluid/ElectrolyteManagement(NIC)

Independent
Weighdaily.

Indicatorofoverallfluidandnutritionalstatus.

Maintainoralrestrictions,bedrestavoidexertion.

Colonisplacedatrestforhealingandtodecrease
intestinalfluidlosses.

Observeforovertbleedingandteststooldailyforoccult
blood.

Inadequatedietanddecreasedabsorptionmayleadto
vitaminKdeficiencyanddefectsincoagulation,
potentiatingriskofhemorrhage.

Notegeneralizedmuscleweaknessorcardiac
dysrhythmias.

Excessiveintestinallossmayleadtoelectrolyte
imbalance,e.g.,potassium,whichisnecessaryforproper
skeletalandcardiacmusclefunction.Minoralterationsin
serumlevelscanresultinprofoundand/orlifethreatening
symptoms.

Collaborative
Administerparenteralfluids,bloodtransfusionsas
indicated.

Maintenanceofbowelrestrequiresalternativefluid
replacementtocorrectlosses/anemia. Note: Fluids

https://www.scribd.com/doc/17471595/NursingCarePlanforInflammatoryBowelDisease

1/2

9/10/2016

NursingCarePlanfor"InflammatoryBowelDisease"

containingsodiummayberestrictedinpresenceof
regionalenteritis.
Monitorlaboratorystudies,e.g.,electrolytes(especially
potassium,magnesium)andABGs(acidbasebalance).

Determinesreplacementneedsandeffectivenessof
therapy.

Administermedicationsasindicated:
Antidiarrheal(RefertoND:Diarrhea)

Reducesfluidlossesfromintestines.

Antiemetics,e.g.,trimethobenzamide(Tigan),
hydroxyzine(Vistaril),prochlorperazine
(Compazine)

Usedtocontrolnausea/vomitinginacuteexacerbations.

Antipyretics,e.g.,acetaminophen(Tylenol)

Controlsfever,reducinginsensiblelosses.

Electrolytes,e.g.,potassiumsupplement(KClIVK
Lyte,SlowK)

Electrolytesarelostinlargeamounts,especiallyinbowel
withdenuded,ulceratedareas,anddiarrheacanalsolead
tometabolicacidosisthroughlossofbicarbonate(HCO

VitaminK(Mephyton).

).

Stimulateshepaticformationofprothrombin,stabilizing
coagulationandreducingriskofhemorrhage.

https://www.scribd.com/doc/17471595/NursingCarePlanforInflammatoryBowelDisease

2/2