Case (Block A)

Mr. Gonzales is a direct admission from his assisted care facility to the intermediate
care unit with dehydration secondary to profuse diarrhea. He is awake, alert, and oriented
(×3, has a low-grade fever, abdominal cramps, and diarrhea (5 to 10 watery stools a day).
He tells you, “I don’t think I have gone this much in my entire life! I can’t even describe how
bad my bottom feels! I was just getting over my chest infection with all those antibiotic pills.”
You receive the following orders from the primary care provider:
• Vital signs q4h while awake
• IV of lactated Ringer’s solution (LR) @ 150 mL/hr
• BRAT diet
• Stool for occult blood, O&P, and Clostridium difficile
• BR/BRP with assistance
• Skin/wound care consult

Make a Nursing Care Plan using ADPIE Method.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Diarrhea related to After 8 hours of After 8 hours of

antibiotic medication. implementing ● Provide fluids ● To replace/ nursing care, the
intervention, the (lactated supply the patient have been
“I don’t think I have patient will be free Ringer’s lost fluids and free from
gone this much in my from abdominal solution) via electrolytes discomfot;and normal
discomfort and would IV. the patient's bowel functioning has
entire life! I can’t
reestablish normal body had lost. been patrially met,
even describe how bowel functioning. decreasing the
bad my bottom feels! ● To observe passing of stool.
changes and
I was just getting ● Monitor vital monitor vital
over my chest signs at every statistics of
infection with all 4 hour the patient
because
those antibiotic pills.” drastic
stated by the patient. alterations
indicate
underlying
medical
Objective:
problems

● Awake, alert, ● The diet is

low in fiber
and oriented ● Provide a that may help
(x3) BRAT diet stop diarrhea
by firming up
● Low-grade
the patient’s
fever stool
● Abdominal
cramps ● Patient
● Diarrhea (5 to cannot exert
10 watery force in
● Provide activities as it
stools a day) assistance in may worsen
bedrest and the patients
bathroom health status
privileges thus bedrest
and bathroom
privileges of
the patient is
needing
assistance

● Necessary to
evaluate and
diagnose the
patient’s
● Prepare for condition.
required test
(Stool for
occult blood,
O&P, and
Clostridium
difficileV)