Problem/Complai Planning Nursing Intervention Rationale

nt
1. Vomiting  Client will have a 1) Determine causes 1) Assessing the
negative stool of nausea. patient with the
2) Assess nausea causes of
culture.
characteristics: nausea will
 Client will pass  History guide the choice
soft, formed stool  Duration of interventions
no more than 3 x a  Frequency to be used.
day.  Severity Treatment may
 Patient’s urinary  Precipitatin not be needed
g factors if the stimulus is
output will
 Medication eliminated.
maintain at least s 2) A thorough
30 cc/hr.-Patient  Measures assessment and
will be able to used to evaluation of
tolerated clear alleviate nausea can help
the determine
liquids without
problem interventions to
vomiting within 24 lessen or ease
3) Record the
hours. patient’s the problem.
 Patient will have hydration status, Nausea is
equal intake and daily weights, BP, usually
output within 24 intake and output, correlated with
and assessing skin vomiting that
hours.
turgor. can change a
 Patient’s patient’s
4) Provide an emesis
electrolyte levels basin within easy hydration status
will remain within reach of the because of fluid
normal range patient. loss.
through out 5) Educate and assist 3) Nausea and
patient about oral vomiting are
hospital stay.
hygiene. closely related.
 Patient will rate Keep emesis
6) Assist the patient
pain less than 3 on in diagnostic basin out of
1-10 scale within 6 testing sight but within
hours. preparation. the patient’s
 -Patient will report 7) Eliminate strong reach if nausea
odors from the has a
feeling less psychogenic
surrounding (e.g.,
lethargic within 48 perfumes, component.
hours. dressings, emesis) 4) This is
8) Maintain fluid associated with
balance in anorexia and
patients at risk. excessive
9) Allow the patient salivation. Oral
to use hygiene helps
nonpharmacologic alleviate the
 al nausea control condition and
techniques such facilitates
as relaxation, comfort.
guided imagery, 5) A series of tests
music therapy, may be used to
distraction, or determine the
deep breathing contributing
exercises. factor (e.g.,
10) Apply upper
acustimulation gastrointestinal
bands as ordered, tract study,
or apply abdominal
accupressure. computed
11) Introduce cold tomography
water, ice chips, scan,
ginger products, ultrasonograph
and room y.)
temperature 6) Strong and
broth or bouillon noxious odors
if tolerated and can contribute
appropriate to the to nausea.
patient’s diet. 7) Sufficient
12) Give frequent, hydration
small amounts of before surgery
foods that appeal or
to the patient. chemotherapy
 Dry food has been shown
like to reduce the
crackers or risk of nausea in
toast these situations.
 Bland, 8) These methods
simple have helped
foods like patients
broth, rice, alleviate the
bananas, condition but
or Jell-O needs to be
used before it
13) Tell patient to occurs.
avoid foods and 9) Stimulation of
smells that trigger the Neiguan P6
nausea. acupuncture
14) Position the point on the
patient upright ventral surface
while eating and of the wrist has
for 1 to 2 hours been found to
post-meal control nausea
15) Review about the in some points.
prenatal vitamins This has been
the patient is found to be
 taking, if helpful for
pregnant. patients who
16) Administer experience
antiemetics as motion-related
ordered. nausea.
17) Keep rooms well- 10) These aid
ventilated. If hydration.
possible, assist the Ginger helps
patient to go relieve nausea
outside to get whether in
some fresh air. ginger ale,
18) Educate the ginger tea, or
patient or chewed as
caregiver about crystallized
appropriate fluid ginger. Fluids
and dietary that are too
options for cold or hot may
nausea. be difficult to
19) Educate the tolerate.
patient to take 11) This approach
prescribed will help
medications as maintain
ordered. nutritional
20) Education the status. For
patient about the some patients,
importance of an empty
changing positions stomach
slowly and calmly. exacerbates
21) Educate patient or nausea.
caregiver the use 12) Crackers or
of toast before
nonpharmacologic rising are
al nausea control especially
techniques such known to be
as relaxation, effective for
guided imagery, pregnancy-
music therapy, related nausea.
distraction, or 13) Patients may
deep breathing endure these
exercises. types of foods.
22) Evaluate the They should
patient’s response attempt to
to antiemetics or consume more
interventions to when nausea is
alleviate the absent.
condition. 14) Strong and
23) Inform the patient noxious odors
or caregiver to can contribute
seek medical care to nausea.
if vomiting 15) This can be
develops or helpful in
persists longer reducing the
than 24 hours. risk.
16) Having too
much iron may
cause nausea,
and switching
to a different
vitamin could
help.
17) Most
antiemetics
work by
increasing the
threshold of the
chemoreceptor
trigger zone to
stimulation.
Drugs with
antiemetic
actions include
antihistamines,
anticholinergics,
dopamine
antagonists,
serotonin (5-
HT3) receptor
antagonists,
and
benzodiazepine
s.
Glucocorticoids
and
cannabinoids
are useful to
treat
chemotherapy-
induced nausea
and vomiting.
For the
preoperative
patient,
administration
of antiemetics
prior to surgery
has been shown
to reduce
postoperative
 nausea and
vomiting.
18) A well-
ventilated room
or having a fan
close by
promotes easier
breathing.
19) Patients and
caregivers can
promote
adequate
hydration and
nutritional
status by
acknowledging
dietary points
to consider
when
nauseated.
20) Following the
prescribed
schedule for
medications
reduces
episodes of
nausea.
21) Abrupt or gross
movements
may aggravate
the condition.
22) Teaching the
patient and
caregiver
methods to
control nausea
increases the
sense of
personal
efficacy in
managing
nausea.
23) This approach is
helpful in
determining the
effectiveness of
such
interventions.
24) Persistent
 vomiting can
result in
dehydration,
electrolyte
imbalance, and
nutritional
deficiencies.
2. Diarrhea  Patient explains 1) Ask the client 1) Eating
cause of diarrhea about a recent contaminated
history of: foods or
and rationale for
 Drinking drinking
treatment. contaminated contaminated
 Patient consumes water. water may
at least 1500-2000  Eating food predispose the
mL of clear liquids inadequately client to
within 24 hours cooked. intestinal
 Ingestion of infection.
period. 2) Defecation
unpasteurized
 Patient maintains dairy products. pattern will
good skin turgor 2) Evaluate pattern promote
and weight at of defecation. immediate
usual level. 3) Assess for treatment.
abdominal pain, 3) These
 Patient reports
abdominal assessment
less diarrhea cramping, findings are
within 36 hours. hyperactive bowel commonly
 Patient defecates sounds, connected with
formed, soft stool frequency, diarrhea. If
every day to every urgency, and loose gastroenteritis
stools. involves the
third day.
4) Submit client’s large intestine,
 Patient maintains stool for culture. the colon is not
a rectal area free 5) Teach the client able to absorb
of irritation. about the water and the
 Patient states importance client’s stool is
relief from of hand very watery.
washing after 4) A culture is a
cramping and less test to detect
each bowel
or no diarrhea movement and which causative
 Patient has before preparing organisms
negative stool food for others. cause an
cultures. 6) Educate the client infection.
about perianal 5) Hands that are
care after each contaminated
bowel movement. may easily
7) Encourage spread the
increase fluid bacteria to
intake of 1.5 to utensils and
surfaces used in
 2.5 liters/24 hour food
plus 200 ml for preparation
each loose stool in hence hand
adults unless washing after
contraindicated. each bowel
8) Encourage the movement is
client to restrict the most
the intake efficient way to
of caffeine, milk prevent the
and dairy transmission of
products. infection to
9) Encourage the others.
client to eat foods 6) The anal area
rich in potassium. should be
10) Administer gently clean
antidiarrheal properly after a
medications as bowel
prescribed. movement to
prevent skin
irritation and
transmission of
microorganism.
7) Increased fluid
intake replaces
fluid lost in
liquid stools.
8) These food
items can
irritate the
lining of the
stomach, hence
may worsen
diarrhea.
9) When a client
experience
diarrhea, the
stomach
contents which
is high in
potassium get
flushed out of
the
gastrointestinal
tract into the
stool and out of
the
body, resulting
in hypokalemia.
10) Bismuth salts,
 kaolin, and
pectin which
are adsorbent
antidiarrheals
are commonly
used for
treating the
diarrhea of
gastroenteritis.
These drugs
coat the
intestinal wall
and absorb
bacterial toxins.
3. Constipation  Patient maintains 1) Check on the usual 1) It is very crucial to
passage of soft, pattern of elimination, carefully know
including frequency what is “normal”
formed stool at a
and consistency of for each patient.
frequency stool. The normal
perceived as 2) Take account of a frequency of stool
“normal” by the possible laxative and passage ranges
patient. enema use, type, and from twice daily to
 Patient states frequency. once every third or
3) Check out usual fourth day. Dry and
relief from dietary habits, eating hard feces are
discomfort of habits, eating common
constipation. schedule, and liquid characteristics of
 Patient identifies intake. constipation.
measures that 4) Assess the patient’s 2) There is a big factor
activity level. when patient
prevent or treat
5) Classify current becomes
constipation. medications usage dependent on
 Patient or that may lead to laxatives and
caregiver constipation. enemas. Abuse of
verbalizes 6) Feel the need for laxatives and
measures that will privacy for enemas causes the
elimination. muscles and nerves
prevent
7) Evaluate for fear of of the colon to
recurrence of pain with defecation. function
constipation. 8) Consider the degree inadequately in
to which the patient producing an urge
responds to the urge to defecate. In the
to defecate. long run, the colon
9) Know if there is a becomes atonic,
history of neurogenic distended, and
diseases, such as does not respond
multiple sclerosis or normally to the
Parkinson’s disease. presence of stool.
10) Encourage the patient 3) Irregular mealtime,
 to take in fluid 2000 type of food, and
to 3000 mL/day, if not interruption of
contraindicated usual schedule can
medically. lead to
11) Assist patient to take constipation.
at least 20 g of dietary 4) Sedentary lifestyle
fiber (e.g., raw fruits, such as sitting all
fresh vegetable, day, lack of
whole grains) per day. exercise, prolonged
12) Urge patient for some bed rest and
physical activity and inactivity contribute
exercise. Consider to constipation.
isometric abdominal 5) A lot of drugs can
and gluteal exercises. slow down
13) Encourage a regular peristalsis. Opioids,
period for elimination. antacids with
14) Digitally eliminate the calcium or
fecal impaction. aluminum base,
15) Discuss with a antidepressants,
dietitian about dietary anticholinergics,
sources of fiber. antihypertensives,
general anesthetics,
hypnotics, and iron
and calcium
supplements can
cause constipation.
6) Defecating is a
private thing. Most
patients may have a
hard time having a
bowel movement
away from the
sense of privacy in
their home.
7) Conditions such as
hemorrhoids, anal
fissures, or other
anorectal disorders
that are painful can
cause the patient to
ignore the urge to
defecate, which
over time results in
a dilated rectum
that no longer
responds to the
presence of stool.
8) Ignoring the urge to
defecate eventually
 leads to chronic
constipation becaus
e the rectum no
longer senses or
responds to the
presence of stool.
The longer the stool
stays in the rectum,
the drier and
harder it becomes.
This will make the
stool difficult to
pass.
9) Neurogenic
disorders may
decrease peristaltic
activity.
10) Sufficient fluid is
needed to keep the
fecal mass soft. But
take note of some
patients or older
patients having
cardiovascular
limitations
requiring less fluid
intake.
11) Fiber adds bulk to
the stool and
makes defecation
easier because it
passes through the
intestine essentially
unchanged.
12) Movement
promotes
peristalsis.
Abdominal
exercises
strengthen
abdominal muscles
that facilitate
defecation.
13) Most people
defecate following
the first daily meal
or coffee, as a
result of the
gastrocolic reflex.
 14) Stool that remains
15) A person with
4. Abdominal Pain  Patient 1) Assess pain 1) We must have a
demonstrates the 2) Control pain:
repositioning,
use of appropriate
heat/cold,
diversional medications (muscle
activities and relaxants, analgesics),
relaxation skills. and so forth (all as
 Patient describes clinically appropriate)
satisfactory pain 3) Assess bowel
movements (color,
control at a level consistency,
less than 3 to 4 on frequency, amount)
a rating scale of 0 4) Ensure adequate
to 10. hydration; may 2) Patients who are in
 Patient displays require intravenous
fluids
improved well-
5) Assess bowel sounds
in the rectum for
long periods
becomes dry and
hard; debilitated
patients, especially
older patients, may
not be able to pass
these stools
without manual
assistance.
enough knowledge
about the matter
will recommend
sources of
fiber consistent
with the patient’s
usual eating habits.
A patient
unaccustomed to a
high-fiber diet may
experience
abdominal
discomfort and
flatulence; a
progressive
increase in fiber
intake is
recommended.
detailed baseline so
we not only know
how to treat
appropriately but
also to know if it
has changed. (For
example, a sudden
relief of pain in a
patient with
appendicitis
indicates rupture
and an emergency.)
pain have trouble
participating in
care, relaxing,
 being such as 6) Facilitate normal sleeping, and
baseline levels for bowel patterns healing. Do what is
7) Record intake and necessary to
pulse, BP,
output proactively treat
respirations, and 8) Prevent infection the patient’s pain,
relaxed muscle 9) Assess abdominal and notify the
tone or body distention, report provider of changes
posture. changes in size and or an inability to
 Patient uses quality as appropriate provide adequate
relief.
pharmacological
3) This will aid the
and provider in making
nonpharmacologic clinical decisions
al pain-relief significantly. It is
strategies. essential to report
 Patient displays bowel movement
characteristics and
improvement in frequency
mood, coping. accurately to aid in
this important
decision making.
This also ensures
accurate intake and
output recording.
4) Patients with
abdominal pain
may have a
diminished
appetite, be NPO,
or not want to drink
fluids. Assess and
promote
appropriate fluid
balance, which may
requiring notifying
the provider of a
decreased oral
intake and need for
intravenous fluids
to maintain fluid
balance.
5) Essential to know
their quality as a
baseline and to
routinely reassess
to detect changes.
If a patient had
bowel sounds, but
now does not, it is
 essential to detect
that and notify the
provider, as the
patient may not
experience any
symptoms.
6) Abdominal pain can
be due to issues
with the GI tract.
Therefore, it’s
essential to
proactively address
issues like nausea,
vomiting,
constipation, and
diarrhea as
clinically
appropriate. This
can lessen
7) Patients with
abdominal pain
may not be taking
in the necessary
amount of fluids or
foods, or their
urinary and/or
bowel output may
be lacking. Accurate
I&O is essential for
appropriate clinical
decision making.
8) Abdominal pain
may have been
caused by a
pathogen
(gastroenteritis, for
example). It is
essential to
promote adequate
hand hygiene and
infection
prevention to
prevent the spread
to others or
preventing the
issue from
resolving.
9) Patients may be
experiencing
abdominal
distention as part of
the underlying
disease process