Name of Patient Maria Labo Age/Gender: 30 years old.

Ward: Room no:

Chief Complaint: Abdominal pain c watery stools Physician: Dr. Quack
Diagnosis: Acute Gastroenteritis

Date/ Cues N Nursing Diagnosis Patient Outcome Nursing Interventions Implementations

Time e
e
d
Deficient fluid volume r/t After 8 hours of Nursing  Measure intake 1
J S: “Humok kaayo excessive losses Interventions, the patient and output q 4°.
A akoang tae unya N through normal routes as fluid and blood volume will Record and
sige kog kalibang.” U report significant
N evidenced by frequent return to normal and;
T changes. Include
U passage of loose watery
R urine, and stools.
A O: stool. a. Patient will R: Tachycardia,
R I report
 ( + ) sunken dypnea, or
Y eyeballs. T Rationale: understandin hypotension may
 ( + ) poor I g of causative indicate fluid
Rapid propulsion of
skin turgor. O factors for volume deficit or 2
2 intestinal contents fluid volume
5  watery stool N through the small bowels electrolyte
deficit imbalance.
6-9 times in
may lead to a serious b. Patient will
1 day  Monitor and
2 fluid volume deficit. The maintain fluid record vital signs
 poor oral
0 body would want to volume at q 2° or as often
intake
2 expel the foreign functional as necessary 3
 weakness level, well
1  vomiting 3x objective as much as until stable. Then
hydrated, monitor and
for a span of possible thus it doesn’t intake is
7:00 3-4 hours undergo its “normal” record vital signs
equal as q 4°.
AM  Pain scale of speed, with that, the output, and
8/10 R: Tachycardia,
digestive system organs normal skin dyspnea, or
 Stool exam 4
are not able to absorb turgor. hypotension may
revealed (+)
 ova the excess fluids that are indicate fluid
Seen usually absorbed by the volume deficit or
entamoeba body. electrolyte
hysolitica imbalance.
 V/S as  Assess skin
Reference:
follows: turgor and oral
BP: 170/100mmHg Mattm, V. (2011). The mucous
PR: 82 bpm Gastroenteritis. membranes q 4°.
RR: 40 bpm, and Retrieved january 25, R: to check for
T: 36.7°C 2021 from dehydration
https://vdocuments.mx/7  Provide frequent 5
-gastroenteritis-nursing- oral care
R: To prevent
care-plans-
from dryness
nurseslabs.html  Encourage
patient to have
small frequent
meals
R: Help reduce
stomach
distention and 6
pain after eating
 Instruct patient
when allowed to
eat to start with
liquids then
progress to bland
foods like
crackers, 7
bananas, toast,
etc. and avoid
caffeine, alcohol,
tea.
 R: It would allow
bowel or
intestinal tract to
rest and adjust
that could help
reduce
pain/cramping.

8

10

Assess factors that

aggravate pain
Rationale: Helpful in
establishing diagnosis
and interventions
needed

Administer pain
medication as ordered
by the physician.
Rationale: to relieve the
pain

Assess 30 minutes after

giving medication
Rationale: to check for
effectiveness and if pain
is reduced

Advise patient to
position self in semi-
fowlers or any position
that provide comfort
Rationale: Positioning
the self reduces
abdominal tension and
promotes sense of
control.

Instruct patient to do
deep breathing exercise
Rationale: Deep
breathing facilitate
expansion of the
abdomen. Thus, help
lessen the pain

Provide comfort
measures like back rub,
reposition, clean and
quite environment.
Rationale: To promote
relaxation and allow
patient to rest

Provide diversional
activities such as
reading, watching tv,
and/or playing board
games
Rationale: This would
help patient refocus or
divert its attention to
other things

Monitor Vital Signs

noting tachycardia,
increased in respirations
and hypertension
Rationale: Changes in
these may indicate
acute pain or discomfort

Encourage patient to
have small frequent
meals
Rationale: Help reduce
stomach distention and
pain after eating

Instruct patient when

allowed to eat to start
with liquids then
progress to bland foods
like crackers, bananas,
toast, etc. and avoid
caffeine, alcohol, tea.
Rationale: It would
allow bowel or intestinal
tract to rest and adjust
that could help reduce
pain/cramping.

Reference:
Vera, M. (2020). Acute
Pain Nursing Care Plan.
Retrieved January 27,
2021 from
https://nurseslabs.
com/7-inflammatory-
bowel-disease-nursing-
care-plans/4/

Bitram, T. (2017). The

14 foods to eat when
you have stomachache.
Retrieved January 25,
2021 from
https://www.insider.com/
What-to-eat-when-you-
have-a-stomachache-
20178