ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Risk for The term After 8 hours of  Provide oral care at  Dry mouth from After 8 hours of
“Nakakaranas ako deficient inflammatory nursing least every 12 hours an NPO status can nursing
ng sakit ng tiyan fluid volume bowel disease intervention the cause a build up intervention the
tapos nakakailan related toe (IBD) describes a patient will of bacteria and patient the
dumi tapos kapag excessive group of disorders maintain fungus in the patient was able
dumudumi ako losses in which the adequate fluid mouth resulting in tp maintain
may dugo yung through intestines become volume as ulcerations, thrush adequate fluid
dumi ko” as frequent inflamed. It has evidence by and cavities. volume as
verbalized by the diarrhea. often been thought good skin turgor  Weigh daily  Indicator of evidence by
patient of as an and balance overall fluid and good skin turgor
autoimmune intake and nutritional status and balance
disease, but output.  Ascertain onset and  To assess intake and
research suggests pattern of diarrhea etiology. Chronic output
OBJECTIVE: that the chronic diarrhea (caused
 Restlessness inflammation may by irritable bowel
 Fever not be due to the syndrome,
 Irritability immune system infectious
 Facial attacking the body diseases affecting
grimace itself. Instead, it is  Observe and record colon such as
 Dry skin a result of the stool frequency, IBD).
 Weigh loss immune system characteristics,  Helps
attacking a amount, and differentiate
V/S taken as harmless virus, precipitating individual disease
follows bacteria, or food in factors. and assesses
T: 37.9˚C the gut, causing severity of
PR: 72 bpm inflammation that  Observe for episode.
RR: 25 bpm leads to bowel presence of
BP: 120/ 80 injury. associated factors,
mmHg such as fever,chills,
abdominal pain,  To assess
cramping, bloody causative factors
 stools, emotional and etiology
upset, physical
exertion and so
forth.  Rest decreases
 Promote bedrest, intestinal motility
provide bedside and reduces the
commode. metabolic rate
when infection or
hemorrhage is a
complication.
Urge to defecate
may occur
without warning
and be
uncontrollable,
increasing risk of
incontinence or
falls if facilities
are not close at
hand.
 Reduces noxious
 Remove stool odors to avoid
promptly. Provide undue patient
room deodorizers. embarrassment.
 Avoiding
 Identify and restrict intestinal irritants
foods and fluids promote intestinal
that precipitate rest and reduce
diarrhea (vegetable intestinal
s and fruits, whole- workload.
grain cereals,
condiments,
carbonated drinks,
 milk products).
 Provides colon
 Restart oral fluid rest by omitting or
intake gradually. decreasing the
Offer clear liquids stimulus of foods
hourly; avoid cold and fluids.
fluids. Gradual
resumption of
liquids may
prevent cramping
and recurrence of
diarrhea;
however, cold
fluids can
increase intestinal
motility
 May signify that
toxic megacolon
 Observe for fever, or perforation and
tachycardia, peritonitis are
lethargy, imminent or have
leukocytosis, occurred,
decreased serum necessitating
protein, anxiety, immediate
and prostration. medical
intervention.
 used to determine
 Collect and monitor if there is blood or
labs WBCs in the stool

Ma. Paula R. Ical

BSN-3A