PROBLEM LIST

Name: L, L. Chief Complaint: LBM and Vomiting

Age: 70 years old Diagnosis: Acute Gastroenteritis with severe Dehydration

CUES PROBLEM RANK PHYSIOLOGIC BEHAVIORAL

ACTUAL POTENTIAL ACTUAL POTENTIAL

SUBJECTIVE: Diarrhea 1 Fluid volume deficit related to Risk for Electrolyte Impaired comfort related to Risk for mood
active fluid volume (prolonged imbalance related to inadequate control to regulation related to
"Ga sigi na siya og suka kalibang, sa diarrhea) as evidence by insufficient fluid environment or situation as discomfort
us aka adlaw, sa buntag mga ika 5 frequent defecation secondary volume. evidence by bowel urgency
nya mag udto sa sunod-sunod na pod to Acute Gastroenteritis. even when at rest.
og kalibang. Sigi nlng siya og hidga
sa katre" as verbalized by the family Vomiting 2 Gastrointestinal irritation Risk for imbalance Powerlessness related to Risk for decreased
member of the patient. related to unpleasant sensory nutrition less than the inadequate knowledge to activity tolerance
stimuli as evidence by body requirements manage a situation as related to impaired
OBJECTIVE: frequent defecation associated related to inadequate evidence by staying at bed all physical mobility.
with nausea and vomiting. interest in food. day and unable to perform
-vaguely weak in appearance activities.
-abnormal capillary refill time
-with poor skin turgor Hypertension 3 Deficit knowledge regarding Risk for decreased Anxiety related to change in Risk for risk-prone
potential complications related cardiac output related health status as evidenced by behavior related to
Vital Signs: to lack of information as to increase preload. awareness of physiological condition requiring
Temp: 37.7°C evidence by blood pressure of symptoms. change in
BP: 140/90 mmHg 140/90 mmHg.
RR: 16 cpm
PR: 70 bpm

NURSING CARE PLAN

Name: L, L. Diagnosis: Acute Gastroenteritis with severe Dehydration

Age: 70 years old Ward: Male Conference Ward

Chief Complaint: LBM and Vomiting

General Objective: To facilitate the maintenance of fluid and electrolyte balance.

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE: Fluid volume deficit Entry of Within 8 hours of INDEPENDENT: After 8 hours of clinical
related to active fluid microorganisms on the clinical duty, the duty, the goal partially
"Ga sigi na siya og volume (prolonged GI tract patient will be able to: 1. Monitor vital signs To obtain baseline met.
suka kalibang sa usa diarrhea) as evidence especially blood data
ka adlaw, sa buntag by frequent defecation • Maintain fluid volume pressure, respiratory As evidenced by:
mga ika 5 niya mag secondary to Acute at a functional level rate and pulse rate
udto ga sunod-sunod Gastrointestis. Inflammation process 1. Capillary refill time
na pod og kalibang, occurs As evidenced by: 2. Assess clients level To evaluate the ability is within normal range
nadugay puro tubig of consciousness and to express needs
nlng iya ginakalibang. 1. Stable vital signs mentation 2. Defecated within
Sigi na lang siya og normal frequency per
Digestive malfunction 2. Good skin turgor
hidga sa katre" as 3. Auscultate abdomen To determine day
verbalized by the presence, location,
family member of the 3. Normal capillary and characteristics of
patient. refill time bowel sounds.
Excessive gas
formation
4. Promote use of To decrease stress
OBJECTIVE: relaxation techniques and anxiety
• Maintain normal
-vaguely weak in pattern of bowel To promote return to
appearance functioning: 5. Increase oral fluid normal bowel
-abnormal capillary GI distention intake and return to functioning.
refill time As evidence by: normal diet, as
-with poor skin turgor tolerated
1. Normal frequency of
Provides estimation of
defecation (0-3 times a
Vital Signs: 6. Monitor total intake fluid needs.
Temp: 37.7°C Increase peristaltic and output, including
BP: 140/90 mmHg movement stool output as
RR: 16 cpm day). possible.
PR: 70 bpm To allow for bowel rest
2. Normal bowel 7. Encourage to and reduces intestinal
movement from watery restrict solid food workload.
LAB: Diarrhea stools to formed and intake, as indicated.
Direct Fecal Smear soft stools. To prevent spread of
Color: Dark Green 8. Emphasize infectious causes of
Consistency: Mushy & importance of hand diarrhea
Mucoid hygiene.
Fluid imbalance
Result:
-No intestinal parasite DEPENDENT:
or ova seen To decrease the
-Presence of Yeast 1. Administer loop pressure caused by
Cells (budding) Fluid volume deficit diuretics (furosemide excess fluid in the
FEW/LPF 20 mg BID IVVT) as heart and lungs by
ordered. inhibiting sodium and
chloride reabsorption.

To provide a broad
2. Administer antibiotic defense against the
(Ceftriaxone 2 mgs OD bacteria that caused
IVTT) as ordered. the infection.

To treat ulcers of the

3. Administer antiulcer stomach and intestines
agent (Ranitidine 50 and to prevent
mg q8H IVTT) as intestinal ulcers from
ordered. coming back.

To stop the growth and

production of the
4. Administer protozoal
antiprotozoal
(Metronidazole 500 mg
q6H IVTT) as ordered.
 To aid the body retain
potassium.
5. Administer diuretics
(Spironolactone 25 mg
BID 1 tab) as ordered.

COLLABORATIVE: To alleviate the

condition
1. Assist in the
treatment of underlying
condition and
complications of
diarrhea. To prevent
reoccurrence
2. Discuss the
possibility of
dehydration and the
importance of proper
fluid replacement to
the caregiver of the
patient To provide the patient
with a support group
3. Encourage the
client's significant
other(s) to help the
patient to cooperate
with interventions.
Reference:
Nurse’s Pocket Guide, Sixteenth Edition. F.A. Davis

LABORATORY RESULTS
Name: L, L. Chief Complaint: LBM and Vomiting
Age: 70 years old Diagnosis: Acute Gastroenteritis with severe Dehydration

LABORATORY TEST NORMAL RESULT IMPLICATION NURSING CONSIDERATION

VALUE

FECALYSIS

Direct Fecal Smear Test None Yeast Cells (budding) May Indicate Acute Gastroenteritis Monitor vital signs frequently.
FEW/LPF
Record fluid intake and output, including stool output.

Observe for the presence of associated factors, such

as fever or chills, abdominal pain and cramping, bloody
stools, emotional upset, physical exertion and so forth.

Restrict solid intake.

DRUG STUDY
Name: L.L.
Age: 70 years old
Diagnosis: Acute Gastroenteritis with severe Dehydration

Name of Drug Classification Mechanism of Action Indication Adverse Effects Nursing Consideration Patient Teaching

Generic: Therapeutic Inhibits sodium and Hypertension CNS: vertigo, headache, dizziness, Monitor weight, BP, and Inform the patient to
Furosemide class: chloride reabsorption paresthesia, weakness, restlessness, pulse rate routinely with expect increased
Antihypertensive at the proximal and fever. long term use. frequency volume of
distal tubules and the urination.
Dosage: Pharmacologic ascending loop of CV: orthostatic hypotension, Monitor fluid intake and
class: Loop Henle. thrombophlebitis with I.V. electrolyte, BUN, and Instruct the patient to
20 mg diuretics administration. carbon dioxide levels stand slowly to prevent
frequently. dizziness.
EENT: transient deafness, blurred or
Route of yellowed vision, tinnitus. Monitor signs of Advise the patient to
Administration: hypokalemia and muscle immediately report
IVTT GI: abdominal discomfort and pain, weakness. ringing ears, severe
diarrhea, anorexia, nausea, vomiting, abdominal pain, or sore
Frequency: constipation, pancreatitis. Monitor older adults, who throat and fever; these
BID are especially susceptible symptoms may indicate
GU: azotemia, nocturia, polyuria, to excessive diuresis, toxicity.
frequent urination, oliguria. because circulatory
Timing: collapse and Advise patient to eat a
Hematologic: agranulocytosis, aplastic thromboembolic consistent amount of
8am-8pm anemia, leukopenia, complications are potassium-rich foods
thrombocytopenia, anemia. possible because diuretics leads
to potassium wasting
Hepatic: hepatic dysfunction, jaundice. Assess signs of metabolic action that may lead to
alkalosis: drowsiness, hypokalemia.
Metabolic: volume depletion and restlessness.
dehydration, asymptomatic
hyperuricemia, impaired glucose
tolerance, hypokalemia, hypochloremic
 alkalosis, hyperglycemia, dilutional
hyponatremia, hypocalcemia,
hypomagnesemia.

Musculoskeletal: muscle spasm.

Skin: dermatitis, purpura,

photosensitivity reactions, transient
pain at I.M. injection site, toxic
epidermal necrolysis, Stevens-s
Johnson syndrome, erythema
multiforme.

Other: gout.

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action
 Generic: Therapeutic Inhibits cell-wall UTI; intra-abdominal GI: pseudomembranous Monitor patient for Tell patient to report adverse
Ceftriaxone class: synthesis, colitis, diarrhea. superinfection, diarrhea, and reactions promptly.
sodium Antibiotics promoting osmotic anemia and treat appropriately
instability; usually Hematologic: eosinophilia, Instruct patient to report
Pharmacologic bactericidal thrombocytosis, leukopenia. discomfort at IV injection
Dosage: class: Third- site.
generation Skin: pain, induration,
2 gms cephalosporin tenderness at injection site, Tell patient to notify
rash. prescriber about loose stools
or diarrhea.
Route of Other: hypersensitivity
Administration: reactions, serum sickness,
anaphylaxis
IVTT

Frequency:

OD

Timing:

8am

Name of Drug Classification Mechanism of Action Indication Adverse Effects Nursing Consideration Patient Teaching
 Therapeutic Inhibits the action of Active duodenal or CNS: confusion, dizziness, Monitor signs of Advise patient to avoid
Generic: hypersensitivity reactions,
class: Antiulcer histamine at the benign gastric ulcer. drowsiness, hallucinations, alcohol and foods that
Ranitidine agents H2 receptor site located headache. including pulmonary may cause an increase
primarily in gastric symptoms (tightness in the in GI irritation.
Pharmacologic parietal cells, resulting in CV: ARRHYTHMIAS. throat or chest, wheezing,
Dosage: cough, dyspnea) or skin
class: inhibition of gastric acid
Histamine secretion. GI: constipation, diarrhea, reactions.
50mg
H2 antagonists nausea. GU: decreased
sperm count, erectile Assess dizziness and
dysfunction. drowsiness that might affect
Route of gait, balance, and other
Administration: functional activities.
Endo: gynecomastia.
IV Monitor other CNS symptoms
Hemat:
such as confusion,
AGRANULOCYTOSIS,
hallucinations, and
APLASTIC ANEMIA,
Frequency: headache.
anemia, neutropenia,
thrombocytopenia. Monitor IM injection site for
Q8 hours
pain, swelling, and irritation.
Local: pain at IM site.
Timing: Report prolonged or
Misc: hypersensivity excessive injection site
reactions, vasculitis. reactions to the physician.
8am-4pm-12pm

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action
 Generic: Therapeutic Direct-acting Bacterial infections CNS: headache, seizures, Monitor LFT results in older Tell patient to avoid alcohol
Metronidazole class: trichomonacide caused by anaerobic fever, vertigo, ataxia, adults and patient with hepatic and alcohol containing drugs
Antiprotozoal and amebicide that microorganism dizziness, syncope, impairment. during and for at least 3 days
works inside and incoordination, confusion, after treatment course.
Pharmacologic Observe patient for edema
Dosage: outside the irritability, depression,
class: Tell patient that a metallic
intestines. It's weakness, insomnia, Record number and character
500mg Nitroimidazoles taste and dark or brown-red
thought to enter encephalopathy, peripheral of stools
urine may occur.
the cells of neuropathy.
microorganisms Advise patient to report all
Route of CV: prolonged QT interval,
that contain nitro adverse reactions
Administration: flattened T wave, edema,
reductase, forming immediately, especially
flushing, thrombophlebitis
unstable neurologic symptoms
IV after IV infusion. EENT:
compounds that (seizures, peripheral
rhinitis, sinusitis,
bind to DNA and neurophaty).
pharyngitis.
inhibit synthesis,
Frequency: causing cell death. Gl: nausea, abdominal pain,
Q6 hours stomatitis, epigastric
distress, vomiting, anorexia,
diarrhea, constipation,
Timing: proctitis, dry mouth, metallic
taste.
8am-2pm-8pm
GU: vaginitis, darkened
urine, polyuria, dysuria,
cystitis, dyspareunia,
dryness of vagina and
vulva, vaginal candidiasis,
genital pruritus, UTI,
dysmenorrhea, decreased
libido.
Hematologic: transient
leukopenia, neutropenia.
 Musculoskeletal: transient
joint pains.
Respiratory: URI.
Skin: rash.
Other: decreased libido;
over growth of non-
susceptible organisms,
candidiasis; flulike
symptoms.

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Antagonizes Hypertension CNS: headache, drowsiness, Monitor electrolyte levels Instruct patient to take drug
 Spironolactone class: aldosterone in the lethargy, confusion, ataxia, (especially potassium), renal consistently either with or
Diuretics distal tubules, fever. function, fluid intake and without food.
Dosage: increasing sodium output, weight, and BP closely.
Pharmacologic and water exertion CV: vasculitis. Tell patient to report all
25 mg class: Monitor older adults closely as adverse effects.
Gl: diarrhea, gastric bleeding,
Potassium- this age group is more
ulceration, cramping, gastritis,
sparring nausea, vomiting.
susceptible to excessive
diuretics- diuresis.
Route of aldosterone GU: renal failure, erectile
Administration: receptor dysfunction, menstrual
antagonist disturbances, postmenopausal
1 tab, Per Orem bleeding, decreased libido.

Frequency: Hematologic: agranulocytosis,

thrombocytopenia. Hepatic:
BID hepatotoxicity.

Timing: Metabolic: hyperkalemia,

hypovolemia, hyponatremia,
8am-8pm mild acidosis, gout.

Skin: urticarial, hirsutism,

maculopapular eruptions, SJS,
toxic epidermal necrolysis.

Other: anaphylaxis,
gynecomastia, breast
soreness.
References: Comerford K. C. (2017). Nursing 2017 drug handbook (37th ed.). Wolters Kluwer.
Nursing 2023 drug handbook (43rd ed.). Wolters Kluwer. Philippine Edition.
DISCHARGE PLAN

Problem Health Teaching Rationale

HYGIENE Recurrence of diarrhea PROMOTIVE
1. Proper food sanitation 1. Instruct the patient to exercise regularly. 1. To maintain normal body weight.
2. Proper handwashing

3. Proper food handling PREVENTIVE

1. Instruct the patient to avoid eating fatty foods. 1. To prevent stomach upset and irritation.
ACTIVITY 2. Instruct the patient to practice handwashing 2. To prevent microorganisms to enter the body.
1. Do light-moderate exercises before and after meals and practice proper
food handling.

DIET

1. Avoid eating foods that could CURATIVE

cause stomach upset and
1. Take going home meds as ordered:
irritation such as fatty foods.
a. Spironolactone is a diuretic.
a. Spironolactone 25 mcg BID PO
2. Eat foods rich in potassium.

3. Increase fluid intake.

REHABILITATIVE
1. Instruct to come back for follow-up check-up 1. To check on the progress of the patient’s
INSTRUCTION
1 week after discharge. condition.
1. Come back 1 week after
2. Instruct S/O to visit the nearest health center 2. To maintain normal blood pressure
discharge for check-up
to check the patient’s blood pressure.
2. Instruct significant other to visit
the nearest health center to
check blood pressure.