NURSING CARE PLAN
Analysis
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Dysfunctional Dysfunctional Short term After 8 hours of nursing
data: “ilang Gastrointestinal motility of the goal: Independent: intervention, the patient
beses po ako Motility related to gastrointestinal After 8 hours of •Administering prescribed performed 2 bowel movements.
nagtatae sa inflammation as tract caused by nursing •Administer medications like Goal met.
isang araw, evidence by inflammation intervention medications as aminosalicylates orally or
tapos may dehydration and could cause the patient will indicated. rectally to manage After 24 hours of nursing
halong dugo” bloody diarrhea shift of the experience no inflammation and motility. intervention, the patient has still
normal process, more than mild abdominal cramping,
such as three formed Administer •Considering tenesmus, but no evidence of
Objective diarrhea or bowel antidiarrheals. antidiarrheals like defecation. Goal partially met.
Data: constipation. movements per loperamide for severe
Bloody Persistent day. diarrhea, but with caution
diarrhea inflammation due to the risk of toxic
could damage Long term megacolon.
Soaks 3-4 the lining of the goal:
adult diapers gastrointestinal After 24 hours •Administer enteral •Prioritizing enteral
daily tract imposing of nursing feedings as indicated. nutrition over parenteral
risks to the intervention, nutrition for malnourished
3-4 times of patient. the patient will patients because of its
loose, bloody have 2 beneficial effects on the
diarrhea episodes of gastrointestinal system.
diarrhea for the
next day. Educating the patient to
•Encourage the avoid NSAIDs like
ibuprofen and naproxen,
patient to avoid as they can exacerbate
medications that can UC symptoms, and to be
worsen symptoms. aware of all potential
medication side effects.
Dependent/
Collaborative
Refer the patient to a Surgery could alleviate
GI specialist to the symptoms and other
assess for possibility manifestations of
of surgery to alleviate Ulcerative Colitis
the inflammation.
Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation
Subjective Risk Deficient Prolonged or Short term Independent: Helps manage a vital After 8 hours of nursing
data: Volume related to extensive goal: •Prevent dehydration: symptom, diarrhea itself intervention, the patient reports
“nanghihina persistent diarrhea diarrhea could typically indicates a more of having adequate fluid intake
po ako sa as evidenced by cause severe After 8 hours of serious gastrointestinal (7-8 cup) for the whole day. Goal
sobrang fatigue, poor skin complications in nursing illness, dietary met.
pagtatae po” turgor and dry skin the long run if intervention the intolerance, a
not treated patient will pharmaceutical side After 24 hours of nursing
Objective promptly. It demonstrate effect, or an infection intervention, the patient serum
Data: manifests as behaviors to electrolytes result is into normal
Poor skin dry skin, poor promote side, with mild fluctuation. Goal
turgor skin turgor, and adequate fluid •Hydrate the patient: •Restore lost fluids and partially met.
can make the intake. Give intravenous fluid electrolytes directly and
Dry mouth patient and electrolyte precisely to correct
experience Long term dosages as directed dehydration and prevent
Sunken eyes more fatigue goal: complications.
than usual. After 24 hours
Urine output of nursing •Encourage increased Promote oral rehydration
of less than intervention, the oral fluids: to moisturize, increase
300 per day patient will Encourage an body fluids, and replace
maintain normal increase in oral fluids losses, utilizing
3-4 times of levels of serum if it is safe to do so in electrolyte-rich options
loose, bloody electrolytes patients with when appropriate for
diarrhea ulcerative colitis. Urge ulcerative colitis.
the patient to drink
electrolyte drinks,
broths, soups, and
water. •Adhering to the
recommended diet,
•Implement the especially during acute
recommended diet: episodes, can help
Whether the patient is minimize diarrhea,
experiencing an acute thereby reducing fluid
episode of colitis or an loss and the risk of
exacerbation, adhere deficient fluid volume by
to the recommended avoiding trigger foods.
diet. Deficient fluid
volume from diarrhea
may be less likely with
a healthy diet and
avoidance of foods
that provoke the
condition.
Dependent/
Collaborative:
Refer the patient to a
nutritionist to develop Special diet plan is often
an appropriate diet an option to avoid
plan specific to the triggers of inflammation
patient’s condition. and abdominal pain
leading to diarrhea.
Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation
Subjective Independent: -After 8 hours of nursing
Data: Acute Pain related Any chronic Short Term interventions, the goal was
“Masakit ang to inflammation of inflammatory Goal: -Assess pain using a -Provides baseline data to met. The patient reported a
tiyan ko, the intestinal disease pain scale (0–10) monitor pain trends and reduction in pain level from
parang may mucosa as affecting the Patient will every 2–4 hours evaluate effectiveness of 8/10 to 3/10.
matinding evidenced by verbal colon and verbalize a interventions.
sakit na hindi report of pain, facial rectum can reduction in -Teach and encourage -Promotes relaxation and -The patient demonstrated use
nawawala.” deep breathing can help reduce the of deep breathing exercises to
grimacing and cause symptoms pain level to exercises or guided perception of pain. help relieve abdominal
- Patient restlessness. like abdominal ≤3/10 within 1 imagery cramping.
reports pain, bloody hour after
abdominal diarrhea, and nursing -Encourage the -Positioning helps reduce -No signs of distress such as
pain rated fatigue. During interventions. patient to assume a abdominal muscle tension facial grimacing or
8/10 on the flare-ups, pain is position of comfort and pressure on inflamed restlessness were observed.
pain scale. often severe due Long Term (e.g., fetal position or intestines. -After 3 days of nursing
to inflammation Goal: knees flexed). intervention pain episodes
Objective of the intestinal Dependent: decreased in frequency and
lining. Patient will
data: -Helps manage and relieve intensity as inflammation was
demonstrate
-Administer pain through managed.
effective pain
-Facial prescribed analgesics pharmacologic action.
management
grimacing and (e.g., acetaminophen
techniques and
guarding or opioids as
maintain
behavior ordered). -Maintains hydration, which
comfort during
observed. is important during flare-
hospitalization.
-Initiate IV fluid ups with diarrhea and
-Restlessness therapy as ordered. prevents further
is noted. complications.
-Reduces bowel
-Provide a low-residue stimulation, allowing the
diet or NPO status colon to rest and heal.
during acute
episodes, as ordered.
