7 Gastroenteritis Nursing Care Plans - Nurseslabs
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2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
7 Gastroenteritis Nursing Care Plans By Matt Vera, RN Nov 4, 2011
74 Facebook
2
122
2
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 Contents [show] http://nurseslabs.com/gastroenteritisnursingcareplans/
1/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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
http://nurseslabs.com/gastroenteritisnursingcareplans/
2/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
Assess general condition and vital signs Auscultate abdomen Discuss the different causative factors and rationale for treatment regimen Restrict solid food intake Provide for changes in dietary intake Limit caffeine and high-fiber foods and so as fatty foods Promote use of relaxation technique Encourage oral fluid intake of fluids containing electrolyte Recommend products like yogurt and cultured milk Emphasize importance of handwashing
For baseline data For presence, location, and characteristics of bowel sounds For patient education To allow for bowel rest and reduce intestinal workload To prevent foods/substances that precipitate diarrhea To prevent gastric irritation To decrease stress and anxiety that can aggravate diarrhea For fluid replacement To restore normal flora 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
http://nurseslabs.com/gastroenteritisnursingcareplans/
3/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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 Review factor that aggravate or alleviate pain Instruct the SO to massage the area where pain is elicited if not contraindicated Encourage pain reduction techniques
Rationale To lessen/alleviate pain caused by various factors (administer meds via IV push) To reduce pain and promote relief/comfort To promote healing and provide nonpharmacological 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
Deep breathing exercises may reduce pain
exercises (DBE)
sensation/ used in pain management To promote timely intervention/ revision of
http://nurseslabs.com/gastroenteritisnursingcareplans/
4/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
Monitor effectiveness of pain medications
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
http://nurseslabs.com/gastroenteritisnursingcareplans/
5/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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
To prevent dehydration & maintain hydration
intake.
status.
Provide frequent oral care
To prevent from dryness
Administer Intravenous fluids as prescribed Determine effects of age. Restrict solid food intake, as indicated Discuss individual risk factors/ potential problems and specific interventions
To deliver fluids accurately and at desired rates. Very young and extremely elderly individuals are quickly affected by fluid volume deficit To allow for bowel rest and to reduced intestinal workload. 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
http://nurseslabs.com/gastroenteritisnursingcareplans/
6/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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 Provide health teaching on the client regarding the organization and time management technique to prevent while on activity Provide enough air coming from the electric fan or from the window Develop and adjust simple activity like brushing his teeth
Rationale To enhance patient ability to participate in activity To monitor patients response to activities 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 Encourage complete bed rest
To determine current status and needs For patient recuperation and recovery
Other Possible Nursing Care Plans http://nurseslabs.com/gastroenteritisnursingcareplans/
7/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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.
See Also: Nursing Care Plans
Matt Vera, RN http://nurseslabs.com
Matt Vera is a registered nurse and one of the main editors for Nurseslabs.com. Enjoys health technology and innovations about nursing and medicine, in general.
http://nurseslabs.com/gastroenteritisnursingcareplans/
8/8
7 Gastroenteritis Nursing Care Plans Nurseslabs
7 Gastroenteritis Nursing Care Plans By Matt Vera, RN Nov 4, 2011
74 Facebook
2
122
2
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 Contents [show] http://nurseslabs.com/gastroenteritisnursingcareplans/
1/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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
http://nurseslabs.com/gastroenteritisnursingcareplans/
2/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
Assess general condition and vital signs Auscultate abdomen Discuss the different causative factors and rationale for treatment regimen Restrict solid food intake Provide for changes in dietary intake Limit caffeine and high-fiber foods and so as fatty foods Promote use of relaxation technique Encourage oral fluid intake of fluids containing electrolyte Recommend products like yogurt and cultured milk Emphasize importance of handwashing
For baseline data For presence, location, and characteristics of bowel sounds For patient education To allow for bowel rest and reduce intestinal workload To prevent foods/substances that precipitate diarrhea To prevent gastric irritation To decrease stress and anxiety that can aggravate diarrhea For fluid replacement To restore normal flora 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
http://nurseslabs.com/gastroenteritisnursingcareplans/
3/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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 Review factor that aggravate or alleviate pain Instruct the SO to massage the area where pain is elicited if not contraindicated Encourage pain reduction techniques
Rationale To lessen/alleviate pain caused by various factors (administer meds via IV push) To reduce pain and promote relief/comfort To promote healing and provide nonpharmacological 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
Deep breathing exercises may reduce pain
exercises (DBE)
sensation/ used in pain management To promote timely intervention/ revision of
http://nurseslabs.com/gastroenteritisnursingcareplans/
4/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
Monitor effectiveness of pain medications
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
http://nurseslabs.com/gastroenteritisnursingcareplans/
5/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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
To prevent dehydration & maintain hydration
intake.
status.
Provide frequent oral care
To prevent from dryness
Administer Intravenous fluids as prescribed Determine effects of age. Restrict solid food intake, as indicated Discuss individual risk factors/ potential problems and specific interventions
To deliver fluids accurately and at desired rates. Very young and extremely elderly individuals are quickly affected by fluid volume deficit To allow for bowel rest and to reduced intestinal workload. 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
http://nurseslabs.com/gastroenteritisnursingcareplans/
6/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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 Provide health teaching on the client regarding the organization and time management technique to prevent while on activity Provide enough air coming from the electric fan or from the window Develop and adjust simple activity like brushing his teeth
Rationale To enhance patient ability to participate in activity To monitor patients response to activities 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 Encourage complete bed rest
To determine current status and needs For patient recuperation and recovery
Other Possible Nursing Care Plans http://nurseslabs.com/gastroenteritisnursingcareplans/
7/8
2/15/2016
7 Gastroenteritis Nursing Care Plans Nurseslabs
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.
See Also: Nursing Care Plans
Matt Vera, RN http://nurseslabs.com
Matt Vera is a registered nurse and one of the main editors for Nurseslabs.com. Enjoys health technology and innovations about nursing and medicine, in general.
http://nurseslabs.com/gastroenteritisnursingcareplans/
8/8
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