Gastroenteritis-NCP

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

Planning

Interventions

Rationale

Evaluation

Subjective:

  • Verbalization of pain with a scale of 6/10 on the abdominal area

 

Objective:

Patient manifested:

  • Hyperactive bowel sounds
  • Audible borborygmi
  • Passage of loose liquid watery stools for more than 3 times

Patient may manifest:

  • Poor skin turgor
  • Dehydration
  • Dry lips and oral mucosa
  • Altered LOC
Short Term:After 2-3 hours of nursing interventions, the patient will verbalize understanding of causative factors and rationale for treatment regimen.

Long Term:

After 1-2 days of nursing interventions, the patient will reestablish and maintain normal pattern of bowel functioning AEB passage of semi-solid stools

  1. Establish rapport
  2. Assess general condition and vital signs
  3. Auscultate abdomen
  4. Discuss the different causative factors and rationale for treatment regimen
  5. Restrict solid food intake
  6. Provide for changes in dietary intake
  7. Limit caffeine and high-fiber foods and so as fatty foods
  8. Promote use of relaxation technique
  9. Encourage oral fluid intake of fluids containing electrolyte
  10. Recommend products like yogurt and cultured milk
  11. Emphasize importance of hand washing
  12. Administer due meds
  1. To gain patient’s trust
  2. For baseline data
  3. For presence, location, and characteristics of bowel sounds
  4. For patient education
  5. To allow for bowel rest and reduce intestinal workload
  6. To allow foods/substances that precipitate diarrhea
  7. To prevent gastric irritation
  8. To decrease stress and anxiety
  9. For fluid replacement
  10. To restore normal flora
  11. To prevent spread of infectious diseases
Short Term:After 2-3 hours of nursing interventions, the patient shall have verbalized understanding of causative factors and rationale for treatment regimen.

Long Term:

After 1-2 days of nursing interventions, the patient shall have reestablished and maintained normal pattern of bowel functioning

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

Planning

Interventions

Rationale

Evaluation

Subjective:Patient verbalizes pain.Objectives:

The patient manifested:

▪Abdominal Pain

▪Appears weak

▪Limited range of motion

▪Restlessness

▪Verbalization of pain with a pain scale of 6/10.

 

The pt. may manifest:

▪Facial grimaces

▪Irritability

▪Impaired thought process

▪Reduced interaction with people

▪sleep disturbances

▪diaphoresis

 

Short term:After 3 hours of NI the patient will report a decrease of pain.

 

Long Term:

After 2 days of nursing interventions the patient will be free from pain and demonstrate relaxational skills.

  1. Establish rapport
  2. Monitor and record vital signs.
  3. Review factor that aggravate or alleviate pain
  4. Instruct the SO to massage the area where pain is elicited if not contraindicated
  5. Encourage pain reduction  techniques
  6. Provide adequate rest
  7. Provide diversional activities like socialization
  8. Administer analgesics to maintain acceptable level of pain if not contraindicated
  9. Instruct client to perform deep breathing exercises (DBE)
  10. Monitor effectiveness of pain medications

 

 

  1. To gain the trust and cooperation of the patient
  2. To provide baseline data and note deviations from normal.
  3. Helpful in establishing diagnosis and treatment needs
  4. To lessen/alleviate pain caused by various factors (administer meds via IV push)
  5. To reduce pain and promote relief/comfort
  6. To promote healing
  7. For client’s comfort and relief from pain
  8. To decrease pain.
  9.  Deep breathing exercises may reduce pain sensation/ used in pain management
  10. To promote timely intervention/ revision of plan of care
Short term:After 3 hrs of nursing interventions the pt. shall have reported pain is relived from a pain scale of 6/10 to 2/10

Long Term:

After 2 days of nursing interventions the patient shall be free from pain as evidenced by demonstration of relaxation skills and diversional activities with the help of the SO.

Deficient Fluid Volume

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

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

Planning

Interventions

Rationale

Evaluation

Subjective: (none)Objective:

The patient manifested:

  • passage of loose watery stool
  • vomiting
  • abdominal cramping
  • dehydration
  • nausea
  • fatigue
  • weakness

 

The patient may manifest:

  • nervousness
  • confusion
  • weight loss
  • decreased skin turgor
  • decreased urine output
  • dry mucous membrane
  • fever

 

 

 

 

Short term:After 4 hours  of nursing interventions, the patient will report understanding of causative factors for fluid volume deficit

Long Term:

After 3 days of Nursing Interventions, the patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

 

  1. Establish rapport
  2. Monitor and record VS
  3. Assess patient’s condition
  4. Monitor Input & Output balance
  5. Maintain adequate hydration, increase fluid intake.
  6. Provide frequent oral care
  7. Administer Intravenous fluids as prescribed
  8. Determine effects of age.
  9. Restrict solid food intake, as indicated
  10. Discuss individual risk factors/ potential problems and specific interventions
  1. To gain patients trust
  2. To obtain base line data
  3. To be aware of the patient’s condition and feeling
  4. to ensure accurate picture of fluid status
  5. To prevent dehydration & maintain hydration status.
  6. To prevent  from dryness
  7. To deliver fluids accurately and at desired rates.
  8. Very young and extremely elderly individuals are quickly affected by fluid volume deficit
  9. To allow for bowel rest and to reduced intestinal workload.
  10. To prevent or limit occurrence of fluid deficit.
Short term:

 After 4 hours  of nursing interventions, the patient shall have reported understanding of causative factors for fluid volume deficit

Long term:

After 3 days of Nursing Interventions, the patient shall have maintained fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

 

 

 

Activity Intolerance

NDx: Activity intolerance related to generalized weakness AEB limited physical activity.

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

Planning

Interventions

Rationale

Evaluation

Subjective:Objective:

Patient may manifest:

  • Weakness
  • Restlessness
  • Physical inactivity
  • Increase respiratory rate
  • Fatigue
  • Low hgb count
  • Low hct count
Short Term:After 4 hours of nursing interventions the patient will identify negative factors affecting activity intolerance and eliminate or reduce their effects.

Long Term:

After 1-2 days of nursing interventions, the patient will report activity tolerance with enhance energy and the patient will participate willingly in necessary or desired activities.

 

  1. Monitor and record vital signs
  2. Provide health teaching on the client regarding the organization and time management technique to prevent while on activity
  3. Provide enough air coming from the electric fan or from the window
  4. Develop and adjust simple activity like brushing his teeth
  5. Assist client with activity
  6. Promote comfort measures on the activity
  7. Cluster nursing care
  8. Ascertain ability to stand and move about degree of assistance
  9. Encourage complete bed rest
  1. To obtain the baseline data
  2. To provide adequate knowledge on the client
  3. To enhance patient ability to participate in activity
  4.  To monitor patients respond to activities
  5.  To prevent overexertion
  6. To protect patient from injury
  7. To prevent over-exhaustion
  8. To determine current status and needs
  9. For patient recuperation and recovery
Short Term:After 4 hours of nursing interventions the patient shall have identified negative factors affecting activity intolerance and eliminate or reduce their effects.

Long Term:

After 1-2 days of nursing interventions, the patient shall reported activity tolerance with enhance energy and the patient will participate willingly in necessary or desired activities.

 

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…

Leave a Reply