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Gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus (straining on defecation), and borborygmi (hyperactive bowel sounds).

Nursing Care Plans

The nursing goals for patients with Acute Gastroenteritis are toward avoiding dehydration and management of diarrhea. This post contains 4 nursing care plans and 3 possible nursing diagnoses for AGE.

Diarrhea

Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowel results in diarrhea. Diarrhea is a hallmark sign of gastroenteritis.

Assessment

Patient may manifest

  • Hyperactive bowel sounds
  • Audible borborygmi
  • Passage of loose liquid watery stools for more than 3 times
  • Poor skin turgor
  • Dehydration
  • Dry lips and oral mucosa
  • Altered LOC
  • Pain
  • Stomach cramping

Nursing Diagnosis

  • Diarrhea

Outcomes

  • Patient will verbalize understanding of causative factors and rationale for treatment regimen.
  • Patient will reestablish and maintain normal pattern of bowel functioning AEB passage of semi-solid stools
Nursing Interventions Rationale
Establish rapport To gain patient’s trust
Assess general condition and vital signs For baseline data
Auscultate abdomen For presence, location, and characteristics of bowel sounds
Discuss the different causative factors and rationale for treatment regimen For patient education
Restrict solid food intake To allow for bowel rest and reduce intestinal workload
Provide for changes in dietary intake To prevent foods/substances that precipitate diarrhea
Limit caffeine and high-fiber foods and so as fatty foods To prevent gastric irritation
Promote use of relaxation technique To decrease stress and anxiety that can aggravate diarrhea
Encourage oral fluid intake of fluids containing electrolyte For fluid replacement
Recommend products like yogurt and cultured milk To restore normal flora
Emphasize importance of handwashing To prevent spread of infectious diseases

 

Acute Pain

One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the body’s immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen.

Assessment

Patient may manifest

  • Abdominal Pain
  • Appears weak
  • Limited range of motion
  • Restlessness
  • Verbalization of pain with a pain
  • Facial grimaces
  • Irritability
  • Impaired thought process
  • Reduced interaction with people
  • sleep disturbances
  • Diaphoresis

Nursing Diagnosis

  • Acute Pain

Outcomes

  • Patient will report a decrease of pain.
  • Patient will be free from pain and demonstrate relaxational skills.
Nursing Interventions Rationale
 Review factor that aggravate or alleviate pain  To lessen/alleviate pain caused by various factors (administer meds via IV push)
 Instruct the SO to massage the area where pain is elicited if not contraindicated  To reduce pain and promote relief/comfort
 Encourage pain reduction techniques  To promote healing and provide non-pharmacological pain reduction techniques
 Provide adequate rest  To reduce pain and promote relief/comfort
 Provide diversional activities like socialization  For client’s comfort and relief from pain
 Administer analgesics to maintain acceptable level of pain if not contraindicated  For client’s comfort and relief from pain
 Instruct client to perform deep breathing exercises (DBE)   Deep breathing exercises may reduce pain sensation/ used in pain management
 Monitor effectiveness of pain medications  To promote timely intervention/ revision of plan of care

 

Deficient Fluid Volume

Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. The body would want to expel the foreign objective as much as possible thus it doesn’t undergo its “normal” speed, with that, the digestive system organs are not able to absorb the excess fluids that are usually absorbed by the body.

Assessment

Patient may manifest

  • passage of loose watery stool
  • vomiting
  • abdominal cramping
  • dehydration
  • nausea
  • fatigue
  • weakness
  • nervousness
  • confusion
  • weight loss
  • decreased skin turgor
  • decreased urine output
  • dry mucous membrane
  • fever

Nursing Diagnosis

  • Deficient fluid volume RT excessive losses through normal routes AEB frequent passage of loose watery stool

Outcomes

  • Patient will report understanding of causative factors for fluid volume deficit
  • Patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.
Nursing Interventions Rationale
 Maintain adequate hydration, increase fluid intake.  To prevent dehydration & maintain hydration status.
 Provide frequent oral care  To prevent from dryness
 Administer Intravenous fluids as prescribed  To deliver fluids accurately and at desired rates.
 Determine effects of age.  Very young and extremely elderly individuals are quickly affected by fluid volume deficit
 Restrict solid food intake, as indicated  To allow for bowel rest and to reduced intestinal workload.
 Discuss individual risk factors/ potential problems and specific interventions  To prevent or limit occurrence of fluid deficit.

 

Activity Intolerance

Activity intolerance is insufficient physiological or psychological energy poor endure or complete required or desired daily activities. Because of low hgb and hct level there will be decrease oxygen being delivered to the tissues of the body since the hgb is responsible for the oxygenation of tissue. As a compensatory mechanism, the body will increase its demand of oxygen by increasing respiratory rate of the patient which results then to fatigue. Because of this there will be fast consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the patient has muscle weakness there will be activity intolerance.

Assessment

Patient may manifest

  • Weakness
  • Restlessness
  • Physical inactivity
  • Increase respiratory rate
  • Fatigue
  • Low hgb count
  • Low hct count

Nursing Diagnosis

  • Activity intolerance related to generalized weakness AEB limited physical activity.

Outcomes

  • Patient will identify negative factors affecting activity intolerance and eliminate or reduce their effects.
  • Patient will participate willingly in necessary or desired activities.
Nursing Interventions Rationale
 Provide health teaching on the client regarding the organization and time management technique to prevent while on activity  To enhance patient ability to participate in activity
 Provide enough air coming from the electric fan or from the window   To monitor patients response to activities
 Develop and adjust simple activity like brushing his teeth  To prevent overexertion
 Assist client with activity  To protect patient from injury
 Promote comfort measures on the activity  To prevent over-exhaustion
 Cluster nursing care  To prevent over-exhaustion
 Ascertain ability to stand and move about degree of assistance  To determine current status and needs
 Encourage complete bed rest  For patient recuperation and recovery

 

Other Possible Nursing Care Plans

  • Imbalanced Nutrition: Less than Body Requirements due to insufficient intake and excessive output;
  • Risk for Deficient Fluid Volume (if diarrhea does not occur or intake of fluids is insufficient but does not have any signs of dehydration);
  • Hyperthermia RT inflammatory process.

4 COMMENTS

  1. the reason for low fiber diet is so that the body can pass the infection through the loose stool. with inflammatory diseases like this it is best to let the body cleanse itself. bulky stool would only keep the infection inside the body longer.

  2. with your problem regarding diarrhea… hmm i guess restricting a high fiber diet won't be helpful. i would actually suggest that you will give your patient a high fiber diet so that the stool of you patient will become more bulky, that would prevent further electrolyte loss…

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