ASSESSMENT
Subjective
4 year-old male
patient
Prior to admission,
patient has episodes
of watery stool
and/or LBM
DIAGNOSIS
Diarrhea related to
gastrointestinal
inflammation as
evidenced by
episodes of watery
stool and/or LBM
before admission
PLANNING
After several days of
nursing intervention,
the patient should be
able to:
Reestablish and
maintain normal
pattern of bowel
functioning.
IMPLEMENTATION
Ascertain onset and
pattern of diarrhea,
noting whether acute
or chronic.
Verbalize
understanding of
causative factors and
rationale for
treatment regimen.
Objective
Initial Impressions:
Acute Gastroenteritis
with some signs of
dehydration
Demonstrate
appropriate behavior
to assist with
resolution of
causative factors
(e.g., proper food
preparation or
avoidance
of irritating foods).
Assist in treatment of
underlying conditions
(e.g., infections,
malabsorption
syndrome, cancer) and
complications
of diarrhea.
RATIONALE
EVALUATION
Acute diarrhea
(caused by viral,
bacterial, or
parasitic infections
[e.g., Norwalk,
rotavirus; salmonella,
shigella, giardia;
amebiasis,
respectively];
bacterial foodborne
toxins [e.g.,
Staphylococcus
aureus, Escherichia
coli ]; medications
[e.g., antibiotics,
chemotherapy
agents,
colchicine,
laxatives]; and
enteral tube feedings)
lasts
from a few days up
to a week.
After several days of
nursing intervention,
the patient was able
to:
Reestablish and
maintain normal
pattern of bowel
functioning.
Treatments are varied
and may be as simple
as allowing time for
recovery from a selflimiting gastro
enteritis or may
require complex
treatments, including
Verbalize
understanding of
causative factors and
rationale for
treatment regimen.
Demonstrate
appropriate behavior
to assist with
resolution of
causative factors
(e.g., proper food
preparation or
avoidance
of irritating foods).
antimicrobials and
rehydration, or
community health
interventions for
contaminated food or
water sources.
Note reports of thirst,
less frequent or absent
urination, dry
mouth and skin,
weakness, lightheadedness, and
headaches.
These are
signs/symptoms of
dehydration and need
for rehydration.