Problem/Complain Planning Nursing Intervention Rationale

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1. Vomiting 3 days after. The  Auscultate bowel  Inflammation or
patient will able sounds, noting irritation of the
absence or intestine may be
maintain normal
hyperactive sounds. accompanied by
weight during  Eliminate smells intestinal
nursing from the hyperactivity,
interventions environment. diminished water
 Avoid foods that absorption and
might cause or diarrhea.
exacerbate  Reduces gastric
abdominal stimulation and
cramping like vomiting response.
caffeinated  Might increase
beverages, abdominal
chocolate, orange cramping.
juice.  Provides
 Measure abdominal quantitative
girth. evidence of
 Observe skin or changes in gastric
mucous membrane or intestinal
dryness, and turgor. distention.
Note peripheral  Hypovolemia, fluid
edema and sacral shifts and
edema. nutritional deficits
 Assess abdomen contribute to poor
frequently for skin turgor,
return to softness, edematous tissue.
appearance of  Indicates return of
normal bowel normal bowel
sounds, and function and
passage of flatus. ability to resume
 Weigh daily. oral intake.
 Initial losses or
gains reflect
changes in
hydration.
2. Diarrhea After 8 hours of  Observe and record  It could help
nursing care ,client the frequency, determine the
amount, time, and causative factor
will be able to re-
characteristics of and the need for
establish and stool and for any additional
maintain normal presence of hydration
bowel functioning precipitating replacement.
factors.  These foods can
 Restrict foods as add more irritation
indicated like foods to the stomach.
containing caffeine,  Stress can trigger
too much oil, fiber, frequent passing
milk, and fruits. of stools; with
 Provide a quiet and these measures,
non-stimulating stress could be
environment and avoid odor
teach client of relieved.
relaxation  Hydrating the
techniques to client helps
decrease stress. replace the fluid
 Start venoclysis and and electrolyte he
intravenous loose from
replacement as diarrhea.
indicated.  These agents could
 Administer anti- help halt diarrhea
diarrheal and the
agents/antibiotics progression of this
as indicated. condition to
 Emphasize to dehydration.
increase fluid intake  Rehydration is the
especially those top priority in
containing with diarrhea.
electrolytes, i.e.  This could prevent
ORS. outbreaks and
 Educate on how to spread of
prepare food infectious diseases
properly and the transmitted
importance of good through fecal- oral
food sanitation route.
practices and hand  Discharge health
washing. teaching may be
 Educate on what to necessary to
do in case diarrhea provide adequate
may happen again information on
or with family how to prevent
members to and manage
prevent diarrhea at home.
 dehydration.
3. Constipation After 8hours of  Determine stool  Assists in
nursing color, consistency, identifying
frequency and causative or
intervention, the
amount. contributing
client will establish  Auscultate bowel factors and
or return to normal sounds. appropriate
patterns of bowel  Encourage interventions
functioning increased fluid  Bowels sounds are
intake of 2500 – generally
3000 ml/day within decreased in
cardiac tolerance. constipation.
 Recommend  Sufficient fluid
avoiding gas- intake is necessary
forming foods such for the bowel to
as nuts, peas and absorb sufficient
spicy foods. amounts of liquid
 Instruct client on a to promote proper
high-fiber diet, as stool consistency.
appropriate.  Decrease gastric
 Discuss use of stool distress and
softeners, mild abdominal
stimulants, bulk distension.
forming laxatives or  Fiber absorbs
enemas as water, which adds
indicated. Monitor bulk and softness
effectiveness. to the stool and
speeds up passage
through the
intestines.
 Facilitates
defecation when
constipation is
present. After 8
hours of nursing
interventions, the
client was able to
establish or return
to normal patterns
of bowel
functioning.
4. Abdominal Pain After 2 days of care,  Assess reports of  change in pain
pain will be relieved abdominal characteristics may
cramping or pain, indicate
and patient
noting location, developing
resumes to his duration, intensity complications
normal physical (0-10scale).Report  Reduces
activity. changes in pain abdominal tension
characteristic. and promotes
 Encourage patient sense of control.
to assume position  promotes
of comfort. E.g. relaxation
knees flexed
 Provide comfort
measures(e.g. back
rub, reposition)