NCP: Diarrhea related to irritable bowel disorder as evidenced by lower abdominal pain and loose stools
Assessment             Explanation   of                     Objective                    Nursing Intervention        Rationale                          Evaluation
                                        the
                                  Problem
Subjective:            Diarrhea — loose,            STO:                                      Dx:                                            STO: 
                       watery and possibly          Within 30 mins of nursing                                                                (Goal Met)
“Isang linggo na akong more-frequent bowel          interventions, patient will be able to:                            Aid in identifying After 30 mins of nursing interventions,
nagtatae na may
kasamang dugo,
                       movements — is a
                       common problem. It
                                                         a) Verbalize the rationale for
                                                             treatment regimen
                                                         b) Verbalize understanding of
                                                                                              Observe                  certain diseases
                                                                                                                       and evaluating the
                                                                                                                                          the patient was able to:
sampung beses sa isang may be present alone
                                                                                              and                      severity of an         a) Verbalized the rationale for
                       or be associated with                 causative factor
araw” as verbalized.                                                                                                   event                      treatment regimen
                       other symptoms, such                                                                                                   b) Verbalized understanding of
                       as nausea, vomiting,
 Objective: 
Bloated abdomen
Abdominal cramping
                       abdominal pain or
                       weight loss.
                                                 LTO:
                                                 Within 48 hours of nursing
                                                 interventions, the patient will be able
                                                                                              docume                   When bleeding is
                                                                                                                       a problem, rest
                                                                                                                                                  causative factor
                                                                                                                       slows intestinal
Loose watery stools
with blood
                         Source: Diarrhea.
                         (2021). Retrieved
                                                 to:
                                                      a) Report reduction in frequency
                                                          of stools
                                                                                              nt                       motility and
                                                                                                                       lowers metabolic
                                                                                                                                              LTO:
                                                                                                                                              (Goal Met)
                                                                                                                                             After 48 hours of nursing interventions, the
                         from                         b) Return to more normal stool                                   rate. If facilities   patient was able to:
                         https://www.mayoclinic
                         .org/diseases-
                         conditions/diarrhea/sym
                                                          consistency.
                                                                                              stool                    are not nearby, the
                                                                                                                       urge to urinate
                                                                                                                       may strike
                                                                                                                                                 a) Reported reduction in frequency
                                                                                                                                                    of stools
                                                                                                                                                 b) Returned to more normal stool
                                                                                              frequen
Nursing Diagnosis:       ptoms-causes/syc-
Diarrhea related to      20352241#:~:text=Diarr                                                                        suddenly and be              consistency
irritable bowel disorder hea                                                                                           uncontrolled,
                                                                                              cy,
as evidenced by lower    %20%E2%80%94%20l                                                                              increasing the risk
abdominal pain and loose oose%2C%20watery                                                                              of incontinence
stools                   %20and                                                                                        and falls.
                         %20possibly,more
                         %20than%20a%20few
                         %20days
                                                                                              characte                 to check for the
                                                                                              ristics,                 existence,
                                                                                                                       location, and
                                                                                                                       characteristics of
                                                                                                                       bowel sounds.
amount,
           prevents cramps
           and recurrence of
           diarrhea by
and        avoiding or
           reducing the
           stimulation of
precipit   meals and drinks.
           However, cold
           liquids can
ating      stimulate intestinal
           motility.
factors    There isn't a
Observe    certain diet or set
           of foods that
           causes issues for
and        every person with
           LGB. Depending
           on the patient's
docume     illness and the
           damaged area of
nt
           the intestine,
           dietary
           requirements and
stool      limits must be
           tailored to each
           person.
frequen    Stress responses
cy,        can exacerbate
           conditions when
characte
                           there is a disease
                           present that has no
                           known origin, is
ristics,                   difficult to treat,
                           and may need
                           surgical
amount,                    intervention.
and
precipit
ating
factors
Observe and document
stool frequency,
characteristics, amount,
and precipitating
factors
Promote bed rest, if
indicated, and provided
bed side commode
Tx:
Auscultate the
abdomen
Restart oral fluid intake
gradually, if client has
been on bowel rest
(NPO) during
treatment. Offer clear
liquids hourly and
avoid cold fluids.
Edx:
Discuss patient’s usual
diet. Have patient/SO
identify foods and
fluids that precipitate
patient’s diarrhea and
cramping pain
Provide opportunity to
vent frustrations related
to disease process.
NCP: Acute abdominal pain related to the inflammation or trauma secondary to gastrointestinal disorder
       Assessment            Explanation   of                     Objective                    Nursing Intervention        Rationale                         Evaluation
                                       the
                                 Problem
Subjective:             Acute abdominal pain       STO:                                      Dx:                                           STO: 
“Ang sakit ng tiyan ko” is defined as severe       Within 30 mins of nursing                                                               (Goal Met)
                        pain of more than 6        interventions, patient will be able to:                                                 After 30 mins of nursing interventions,
                                                                                             Observe
as verbalize                                                                                                          Assessment aids
                        hours' duration in a           a) Understand their condition                                  in diagnosis and     the patient was able to:
                        previously healthy                and treatment                                               plan appropriate
                        person that requires
                                                                                             and
                                                       b) Receive fluids                                              interventions            a) Understood the condition and
 Objective:             timely diagnosis and                                                                                                      treatment
Abdominal cramping aggressive treatment,           LTO:                                                                                        b) Received fluids
                        frequently surgical.
                                                                                             docume
                                                   Within 48 hours of nursing
Presence of abdominal                              interventions, the patient will be able                            To identify
muscle guarding or                                                                                                                       LTO:
                                                   to:                                                                complications and  (Goal Met)
tension due to pain                                     a) Return to normal bowel                                     treat early
                                                                                             nt
                                                                                                                                        After 48 hours of nursing interventions, the
                          Source:                           movements                                                                      patient was able to:
                          Greenberger, N. J.,           b) Reports relief from pain                                                            a) Returned to normal bowel
                          Blumberg, R. S., &                                                                                                      movements
Nursing Diagnosis: 
Acute abdominal pain
                          Burakoff, R.
                          (2012). Current
                          diagnosis and
                                                                                             stool                    To provide
                                                                                                                      comfort and
                                                                                                                                               b) Reported relief from pain
                                                                                             frequen
related to the            treatment:
inflammation or trauma Gastroenterology,                                                                              control pain
secondary to
                          hepatology, and
                                                                                             cy,
gastrointestinal disorder
                          endoscopy.
                                                                                                                      To relieve pain
                                                                                             characte
                                                                                             ristics,
amount,
and        To prevent
           aggravation of
           pain
precipit
ating
factors
Observe
and
docume
nt
stool
frequen
cy,
characte
ristics,
amount,
and
precipit
ating
factors
assessed the
precipitating factors,
cause, characteristics,
and severity of pain
monitored vital signs
regularly
tx:
provided a comfortable
semi-fowler’s position
with extra pillows to
support the sides.
Administered
analgesics or narcotics
like morphine as
prescribed
Edx:
Adviced the patient to
splint the abdomen
with the towel or small
pillow while moving