NURSING CARE PLAN NO.

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Subjective: Dysfunctional Within 4 hours of Independent interventions: Within 4 hours of

Patient verbalizes gastrointestinal nursing 1. Note the presence of 1. These conditions nursing
feeling full and motility r/t intervention, the long-term disorders are associated with intervention, the
tight, and gastroenteritis patient will be able such as GERD, hiatal increased, patient was be
intermittent pain in to reestablish and hernia, inflammatory decreased, or able to reestablish
her abdomen maintain normal bowel, and ineffective and maintain
pattern of bowel malabsorption. peristaltic activity. normal pattern of
Objective: functioning bowel functioning
- Abdominal 2. Note lifestyle such as 2. To identify issues
pain travelling to areas with that can affect GI
- Abdominal contaminated food or functioning and
bloating water, poor sanitary health.
- Nausea and living conditions,
vomiting overeating, or intake of
- Hyperthermic foods associated with
- Pale looking gastric diseases.

3. Inspect, auscultate, 3. To identify

percuss, and palpate distension of
abdomen. bowel, distinguish
bowel sounds, and
note any presence
of masses or
enlarged organs.

4. Measure GI input and 4. Manage fluid

output and note losses and
characteristics of replacement needs
drainage. and electrolyte
 balances.

5. Help indicates
5. Encourage patient to worsening of
report changes in nature condition,
or intensity of pain. requiring more
intensive
interventions.

6. To enhance muscle
6. Encourage relaxation and
nonpharmacological reduce discomfort.
interventions such as
positioning, back rub, or
heating pad.
7. The patient may
7. Discuss dietary elect to make
recommendations with adaptations in food
patient and significant choices and eating
others. habits to avoid GI
complications.

Dependent interventions: 8. To relieve pain.

8. Manage pain with
medications as ordered.
9. To replace losses
9. Administer fluid and and to improve GI
electrolytes as circulation and
indicated. function.

10. To reduce the

10. Administer prescribed potential for GI
prophylactic complications such
medications as ordered. as bleeding,
 ulcerations of
stomach mucosa,
and viral diarrheas.

Collaborative interventions: 11. To provide diet

11. Collaborate with sufficient in
dietitian or nutritionist. nutrients by best
possible route –
oral, enteral, or
parenteral.

12. To correct or treat

12. Collaborate in treatment disorders
of underlying conditions. associated with
patient’s current GI
dysfunction.