NURSING CARE PLANNING ABOUT DIARRHEA

NURSING CARE PLANNING ABOUT DIARRHEA

1.      DEFINITION

Diarrhea is a bowel movement in liquid form is more than three times in one day and usually last for two days or more. People with diarrhea will lose body fluids leading to dehydration of the body. Diarrhea is caused by the transport of water and electrolytes in the gut is abnormal.

2.      ETIOLOGY

viruses, bacteria, protozoa, helminth.

3. CLINICAL MANIFESTATION

a. Frequent bowel movements with liquid or watery stool consistency

b. stomach cramps

c. fever

d. nausea

e. gag

f. bloating

g. anorexia

h. weak

i.  pale

j.  Decreased urine output (oliguria, anuria)

k. Decreased skin turgor get ugly

4. COMPLICATION

~ Loss of water and electrolytes: dehydration, metabolic acidosis

~ Shock

~ Seizures

~ Sepsis

~ Acute Renal Failure

~ paralytic ileus

~ Malnutrition

~ Disorders of growth and development

5.LABORATORY STUDIES

Laboratory examinations that can be performed on diarrhea are as follows:

1. Leukocytes Stool (Stool leukocytes): An initial examination of the chronic diarrhea. Indicate the presence of fecal leukocytes role in intestinal inflammation.

2. Examination of parasites or eggs in the stool: To indicate the presence of Giardia E Histolitika on routine examination.

3. Examination of blood: In inflammatory diarrhea found leukocytosis, increased ESR and hypoproteinemia.

4. Laboratory Tests Other: In patients suspected of secretory then be examined as serum VIP (VIPoma), gastrin (Zollinger-Ellison Syndrome), calcitonin (medullary thyroid carcinoma), cortisol (Addison's disease), you urinary 5-HIAA (carcinoid syndrome ).

6.NURSING DIAGNOSES

1. Hipertermi associated with dehydration,

2. Lack of fluid volume associated with intakes less, active fluid volume loss,

3. Hypovolemia shock associated with dehydration

7.INTERVENTION

DX. 1

1. Monitor the temperature as needed

2. Monitor blood pressure, pulse and respiration

3. Monitors temperature and skin color

4. Monitor and report signs and symptoms of hyperthermia

5. Encourage fluid intake and adequate nutrition

6. Teach clients how to prevent high heat

7. Provide antipyretic drugs

8. Provide drugs to prevent or control the chills

DX. 2

1. Define history and the many types of fluid intake and elimination habits

2. Determine the risk factors that lead to fluid imbalance (hyperthermia, diu-Retik, kidney disorders, vomiting, polyuria, diarrhea, diaporesis, exposure to heat, infection)

3. Considering regular BB

4. Monitor vital signs

5. Monitor intake and output

6. Check serum electrolytes and fluid limit when necessary

7. Maintain accurate intake and output records

8. Monitors mucous membranes, skin turgor, and thirst

9. Monitor the color and amount of urine

10. Monitors distended neck veins, krakles, peripheral edema and weight gain.

11. Monitor intravenous access

12. Monitor signs and symptoms of ascites

13. Note the presence of vertigo

14. Maintain infusion flow accordance doctors advice

DX. 3

1 . Assess and record the status of peripheral perfusion . Report significant findings : cold and pale extremities , decreased pulse amplitude , slow capillary refill .

2 . Monitor blood pressure at frequent intervals ; alert on reading more than 20 mmHg below the normal range clients or other indicators of hypotension : dizziness , mental changes , decreased urine output .

3 . If hypotension occurs , place the client in the supine position to improve venous return . Remember that blood pressure > or = 80/60 mmHg for coronary perfusion and adequate renal arteries .

4 . Monitor CVP ( if fitted lines ) to determine the adequacy of venous return and blood volume ; 5-10 cm H2O range usually considered adequate . Values close to 0 indicate hypovolemia , particularly when associated with decreased urine output , vasoconstriction , and increased heart rate were found in hypovolemia .

5 . Observation of decreased cerebral perfusion indicator : restlessness , confusion , decreased level of consciousness . When a positive indicator occurs , protect the client from injury by elevating seat bed and put the bed in the lowest position . Reorientasikan client as indicated .

6 . Monitor the indicator decreased coronary artery perfusion : chest pain , irregular heart rate.