Assessment Nursing Diagnosis Goals and Objective Nursing Interventions Rationale Evaluation

Subjective: Fluid volume deficit >Obtain the patient’s >To provide baseline data for monitoring the patient. Goal met
“I have episodes of related to damage and After 8 hours of initial vital signs. After 8 hours of effective
bloody diarrhea 10 loss of epithelial cells effective nursing >A thorough and good assessment is vital for carrying nursing interventions, the
times a day and lower due to inflammation interventions, the >Observe and record stool out correct interventions to correct the patient’s current patient is able to decrease
abdominal pain” as evidenced by patient will be able to frequency, characteristics, condition frequency of defecation in a
passage of watery decrease frequency of amounts and precipitating range of 1-3 times a day.
Objective: stools, and cramping defecation in a range factors.
abdominal pain of 1-3 times a day.
 Frequent >Promote bed rest, >Rest decreases intestinal motility and reduces the
passage of provide bedside commode. metabolic rate when infection or hemorrhage is a
watery stools complication. Urge to defecate may occur without
warning and be uncontrollable, increasing the risk for
(10 times a day)
incontinence and falls if facilities are not close at hand.
 Abdominal
guarding due to >Reduce noxious odors to avoid undue client
cramping pain >Remove stool properly. embarrassment, and to provide an environment
 weakness Provide room deodorizers. conducive for rest.
 BP-108-66
>Identify foods and fluids >Avoiding intestinal irritants promotes intestinal rest.
 Pulse-110
that precipitate diarrhea.

>Encourage to eat foods >Fruits that are stool former.

like banana and apple.

>Avoid foods that are oily,

spicy and caffeine. >Foods that may precipitate gastric cramping.

>Encourage and offer

fluids gradually. Offer >Provides colon rest by omitting or decreasing the
clear liquids hourly; avoid stimulus of foods/fluids. Gradual resumption of fluids
cold fluids. may prevent cramping and recurrence of diarrhea;
however, cold fluids can increase intestinal motility.

>Presence of disease with unknown cause that is

>Encourage or provide
opportunity for patient to
verbalize or discuss
feelings related to the
disease process.
difficult to cure and that may require surgical
intervention can lead to stress reactions that may
aggravate condition.

>Monitor and observe for >May signify that toxic megacolon or perforation and
 fever, lethargy, peritonitis are imminent/have occurred, necessitating
leukocytosis, decreased immediate medical intervention.
serum protein, anxiety,
and prostration.
>Diarrheal stool is oftentimes highly acidic. This
>Provide good perianal causes anal soreness and irritation in the perianal area
care.
Subjective: “I had some Acute pain possibly After 8 hours of > Assessed conditions > To identify contributing factors to long-term pain Goal partially met. Patient
cramp lower abdominal related to lower nursing interventions, contributing to long-term reported small reduction of
pain which lasts for 1-2 gastrointestinal the patient will be pain pain with the pain scale of
hours and is partially bleeding report reduced pain 8/10 to 7/10.
relieved by defecation” and discomfort > Noted availability of SO > To ensure continuity of interventions

> Noted age and gender of > To determine the perceptive ability of the patient
Objective: the patient

 facial grimace > Evaluated pain > To identify the patient’s responses to pain
 guarding behaviors
behavior
 body weakness > Assessed degree of > To determine factors contributing to increased pain
 abdominal maladjustment
distension
 Pain scale of > Encouraged compliance > To alleviate episodes of pain
8/10 to therapeutic
interventions

> Reduced anxiety and > To ensure proper compliance to interventions

stress

> Included patient and SO > To limit focus on pain

in making the plan of care

> Observed for any > To determine presence of a new physical problem
untoward signs and
symptoms

> Encouraged adequate > To help alleviate pain

rest periods Dependent

> Applied pain > To relieve acute manifestations of the disease process
management interventions,
as indicated
 > To alleviate episodes of pain
> Administered pain
medications, as ordered

Keep fluids within clients reach

and encourage frequent intake as
appropriate.
3. Control humidity and ambient air
temperature as appropriate. Reduce
beddings/clothes, provide tepid
sponge bath.
4. Change po
Keep fluids within clients reach
and encourage frequent intake as
appropriate.
3. Control humidity and ambient air
temperature as appropriate. Reduce
beddings/clothes, provide tepid
sponge bath.
4. Change po
Keep fluids within clients reach
and encourage frequent intake as
appropriate.
3. Control humidity and ambient air
temperature as appropriate. Reduce
beddings/clothes, provide tepid
sponge bath.
4. Change po
Keep fluids within clients reach
and encourage frequent intake as
appropriate.
3. Control humidity and ambient air
temperature as appropriate. Reduce
beddings/clothes, provide tepid
sponge bath.
4. Change po