Name: Bolintiam, Ma. Franchesca M.

Date: July 10, 2021

Section: BSN – 112 Instructor: Ms. Stephanie Esteban

IMPLEMENTATION PHASE
1. What nursing interventions were given in the video? And why do you think it was/ they were given? Please
include your citation.
▪ Please follow the suggested format for Nursing Care Plan.
▪ Cues-Nursing Diagnosis-Analysis-Goals and Objectives-Intervention-Rationale
2. How do you classify those interventions.
-Based on the interventions given, answer the following questions with YES, NO or NOT APPLICABLE (N/A): (These
can be a checklist prior to the implementation.)

Preparation of the Nurse Yes No N/A

1.1 Do you think the nurse needed help to perform the action safely to minimize stress to
the client.
/
1.2 Do you think the nurse was knowledgeable about the rationale of the action as well as
the possible side effects and complications.
/
1.3 Was there a need for the nurse to review any actions he doesn't understand for those
that seem inappropriate or potentially unsafe?
/
1.4 Were the nurse able to determine the feedback points for the client's response that are
aligned with the identified objectives?
/
1.5 Were the activities sequential and scheduled, to allow adequate time for completion?
/
1.6 Is there a need for any alternative and evidenced-based interventions to improve the
plan of care?
/
Preparing the client

1. Is the planned action still need or appropriate?

/
2. Is the client ready to receive the planned intervention?
/
3. Is the client informed of what is expected from them?
/
4. Was he provided privacy or comfort prior to the intervention?
/
Preparing supplies and equipment
1. Are necessary supplies gathered and organized?
/
During implementation

1. Was there a need to adapt or modify the interventions according to the client's age,
values, and health status?
/
2. Did the client participate actively?
/

3. Were interventions done according to the professional standards of care and agency
policies and procedures?
/
4. Were interventions done carefully and accurately?
/
5. Was there a need to delegate activities or tasks?
/
6. Was the nurse able to supervise delegated activities?
/
Post Implementation
 1. Were all planned nursing interventions implemented/ completed?
/
2. Was closure completed between the nurse and the client?
/
2.1 Summary of what actions took place
/
2.2 Information were clarified
/
2.3 Questions of the client were answered
/
2.4 Follow up for evaluation was indicated
/
2.5 Client's response to the intervention was noted
/
3. Is the client left in a safe comfortable environment after the intervention?
/
4. Were any equipment or materials used, removed or disposed of properly?
/
 5. Was the intervention and client's response documented and communicated to
other healthcare team members for continuity and coordination of care?
/

________________________________________________________
1. What other nursing interventions are needed by the client based on the nursing problems you have identified?
Include the rationale or reason for giving intervention. Please include your citation.
▪ Provide for changes in dietary intake to avoid foods or substances that precipitate diarrhea.
▪ Limit caffeine and high-fiber foods; avoid milk and fruits, as appropriate.
▪ Assist in treatment of underlying conditions (e.g., infections, malabsorption syndrome, cancer) and
complications of diarrhea. Therapies can include treatment of fever, pain, and infectious or toxic agents;
rehydration; oral refeeding; and so forth.
▪ Promote use of relaxation techniques (e.g., progressive relaxation exercise, visualization techniques) to
decrease stress and anxiety.
Reference:
Doenges, M. E., Moorhouse, M., & Murr, A. C. (2019). Diarrhea. In Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and
Rationales (Fifteenth ed., p. 243). F.A. Davis Company.

2. How do you classify those interventions.

a. Independent Nursing Intervention
▪ Promote use of relaxation techniques (e.g., progressive relaxation exercise, visualization techniques) to
decrease stress and anxiety.
b. Dependent Nursing Intervention
▪ Provide for changes in dietary intake to avoid foods or substances that precipitate diarrhea.
▪ Limit caffeine and high-fiber foods; avoid milk and fruits, as appropriate.
▪ Assist in treatment of underlying conditions (e.g., infections, malabsorption syndrome, cancer) and
complications of diarrhea. Therapies can include treatment of fever, pain, and infectious or toxic agents;
rehydration; oral refeeding; and so forth.
 Cues Nsg Dx Analysis Planning Interventions Rationale

Objective Acute Based on both Goal: Independent:

epigastric the subjective Administer
▪ Blood pain and objective appropriate 1. Ask client 1. In a healthcare setting,
pressure of related to cues, the client medication to fill up and informed consent allows
140/90 poor is experiencing and complete the you to participate in your
mmHg dietary an actual treatment to consent form own medical care. It
▪ Pulse rate habits as nursing eliminate enables you to decide
of 115 bpm evidenced problem which epigastric which treatments you do
▪ Respiratory by is acute pain as or do not want to receive.
rate of 22 excessive epigastric pain. evidenced Also, informed consent
CPM defecation Not only does by allows you to make
▪ O2 stat of and the client admit decreased decisions with your
98% vomiting, to having pain level, healthcare provider. This
▪ Guarding pain rating unhealthy normal collaborative decision-
behavior of 8/10, eating habits, formed making process is an
▪ Facial grimacing, he also stool, and ethical and legal
grimace and exhibited signs eradicate obligation of healthcare
guarded of discomfort vomiting providers (Nunez, 2019).
Subjective behavior upon
assessment.
2. According to Batto &
▪ Client Patients who Objectives: 2.
Center (2016),
reports experience Reassessment
pain reassessment allows
that he is abdominal pain 1. Patient of the client’s
for patients to
feeling related to will condition,
communicate with staff
epigastric functional demonstrate pain level,
members about the
pain gastrointestinal reduced and bowel
efficacy of their pain
▪ Pain scale disorders are epigastric movement
intervention and can not
of 8/10, also those who pain
only improve the quality
 non- have notably of communication within
radiating, unhealthy 2. Patient the unit, but can allow for
and dietary habits will start to interventions to be
aggravated (Chouliaras et observe adjusted according to
with food al., 2019). healthier patient need.
intake Moreover, a eating
▪ The client study by habits 3. Insertion Intravenous fluid
reports to Andrews et al., of IV line regulation is the control
experience (2020) states 3. Patient of the amount of fluid you
vomiting that both will learn receive intravenously, or
and abdominal pain about the through your
elimination and irritable importance bloodstream. The fluid is
of black bowel of proper given from a bag
tarry stools syndrome hand connected to an
(IRS) are both hygiene and intravenous line. This is a
associated with observe it thin tube, often called an
eating habits, before and IV, that’s inserted into
food allergies, after one of your veins (Ellis,
and preparing 2017).
intolerances. food
This supports
According to Johnson
the diagnosis 4. Patient 4.
(2018), while recovering
that the acute will observe Encouraging
from diarrhea, a person
epigastric pain sufficient the client to
should eat bland, simple
experienced by fluid intake restrict
foods that are easy to
the client could of 1.5 to 2.5 intake of food
digest and will help
be caused by liters per 24 and increase
absorb some water from
his poor hours to fluid intake.
the stool. Liquids are also
dietary habits. replace fluid
vital to recovery. People
To sum it all loss
with diarrhea must drink
up, the plenty of water
problem is a 5. Patient throughout the day and
collaborative will take the should drink an
problem as it given additional cup of water
requires both medications after every loose bowel
nursing and during the movement. Drinking
medical effort designated plenty of water helps
to treat, time frame prevent dehydration and
monitor, and as ordered flush any toxins out of the
implement by the body.
long-term doctor
wellness for
the patient. 6. Providing Bedrest is a relaxation
room to the technique that can decrease
client for stress and anxiety, a factor
bedrest that may cause diarrhea.
(Doenges & Murr, 2019)

Dependent:
1. Many different types
Administering of medications can be
drugs to the given by IV. Some of
patient using the drugs more
the IV line commonly given by this
method include:
chemotherapy drugs such
as doxorubicin,
vincristine, cisplatin, and
paclitaxel. antibiotics
such as vancomycin,
 meropenem, and
gentamicin.

Collaborative: 1. Collecting blood

1. Sending the samples is a frequently
blood sample used method to diagnose
of the patient and monitor diseases, and
for laboratory thanks to blood samples,
testing and long and sometimes
monitoring the painful examinations can
condition of often be
the client avoided. Blood condition
says something about the
patient's overall health
condition and reveals
more specific diseases
and conditions
(Encyclopedia.com,
2019).

2. Sending the Based on an article by

stool and urine Michigan Medicine
sample of the (2009), a stool analysis
patient for is a series of tests done
laboratory on
testing and a stool (feces) sample to
monitoring the help diagnose certain
condition of conditions affecting the
the client digestive tract. These
conditions can include
infection (such as from
parasites, viruses, or
bacteria), poor nutrient
absorption, or cancer.
 References

Blood Specimen Collection | Encyclopedia.com. (2019). Encyclopedia.com.

https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/blood-specimen-collection

Center, G., & Batto, R. (2016). Master’s Projects and Capstones Theses, Dissertations, Capstones and Projects Winter.
https://repository.usfca.edu/cgi/viewcontent.cgi?article=1453&context=capstone#:~:text=Pain%20reassessment%20
allows%20for%20patients

Ellis, M. E. (2017). Intravenous Fluid Regulation: Purpose, Procedure, and More. Healthline.
https://www.healthline.com/health/intravenous-fluid-regulation

Johnson, J. (2018). Intravenous Fluid Regulation: Purpose, Procedure, and More. Healthline.
https://www.healthline.com/health/intravenous-fluid-regulation

Nunez, K. (2019, October 11). Informed Consent in Healthcare: What It Is and Why It’s Needed. Healthline.
https://www.healthline.com/health/informed-consent#definition

Stool Analysis | Michigan Medicine. (2009). Uofmhealth.org. https://www.uofmhealth.org/health-library/aa80714