DATE/TIME FOCUS DATA, ACTION and RESPONSE

1/31/2023 Risk D – Loose stool; fecal urgency; inconsistency

for Deficient along with 6 to 8 times loose bowel
8:00 AM movements per day;
Fluid Volume
A – V/S taken and recorded; Bedside care
done; NPI done; Promote bedrest and
comfort; Observed and documented stool
frequency, characteristics, amount, and
precipitating factors; Advised adequate fluid
intake; Medication administered as per
doctor’s order; Discussed patients usual
3:00 PM
diet; Health teaching rendered to
patient/SO about foods and fluids that
precipitate patient’s diarrhea;
R - Patient was able to report reduction in
frequency of stools, returned to more
normal stool consistency, identified and
avoided contributing factors such as poor
hygiene, eating large amounts of meat and
fibers and drinking poor quality water

A 43-year-old woman with a history of recurrent abdominal pain for 25 years, loose stool, fecal urgency.
In the last 1-2 years, her symptoms have worsened and she experienced severe abdomen pain, fecal
urgency, and inconsistency along with 6 to 8 times loose bowel movements per day. She is not exposed
to alcohol. Her symptoms started deteriorating in recent years with the increase in stress in her personal and
professional life. Due to her improper bowel movements, she had to quit her job which requires a lot of
traveling and her body is not permitting to do that. There is no family history of irritable bowel syndrome or
colon cancer. She was admitted in the hospital last January 30, 2023 with a chief complaint of  abdominal pain
with a pain scale of 7/10. Physical examinations and laboratory test reports showed no signs of weight loss
and no blood in stool.