● Severe pain related to inflammatory process as evidenced by the patient rating pain

9/10.

1. Repositioning INDEPENDENT
2. Ensure adequate hydration INDEPENDENT
3. Apply heat/cold compress INDEPENDENT
4. Give medications (muscle relaxants, analgesics) DEPENDENT
5. Assess abdominal distention, report changes in size and quality as appropriate
INDEPENDENT

Evaluation statement: Shows no signs of pain, Vital signs within normal range.

● Vomiting related abdominal pain evidenced by the patient vomits three times for the last
four hours for about 1-2 cups per vomitus.
1. Maintain fluid balance in patients at risk. INDEPENDENT
2. Position the patient upright while eating and for 1 to 2 hours post-meal. INDEPENDENT
3. Assist the patient in diagnostic testing preparation. INDEPENDENT
4. Educate the patient to take prescribed medications as ordered. INDEPENDENT
5. Give frequent, small amounts of foods that appeal to the patient INDEPENDENT

Evaluation statement: Experience minimal nausea and vomiting

● Diarrhea related to presence of toxins as evidenced by the patient having loose watery
stool seven times for the last 4 hours.

1. Give antidiarrheal drugs as ordered. DEPENDENT

2. Provide perianal care after each bowel movement. INDEPENDENT
3. Evaluate dehydration by observing skin turgor over sternum and inspecting for
longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness,
lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and
symptoms of shock. INDEPENDENT
4. Record number and consistency of stools per day; if desired, use a fecal incontinence
collector for accurate measurement of output. INDEPENDENT
5. Encourage patient to eat small, frequent meals and to consume foods that normally
cause constipation and are easy to digest. INDEPENDENT

Evaluation statement: Report relief of diarrhea