2/15/2016
7GastroenteritisNursingCarePlansNurseslabs
7 Gastroenteritis Nursing Care Plans
ByMattVera,RN Nov4,2011
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Gastroenteritisis an inflammation of the stomach and intestinal tract that primarily affects the
small bowel.The major clinical manifestations are diarrhea of varying degrees and abdominal pain
and cramping.Associated clinical manifestations are nausea, vomiting, fever anorexia, distention,
tenesmus (straining on defecation), and borborygmi (hyperactive bowel sounds).
NursingCarePlans
Contents [show]
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The nursing goals for patients with Acute Gastroenteritis are toward avoiding dehydration and
management of diarrhea. This post contains 4 nursing care plans and 3 possible nursing diagnoses
for AGE.
Diarrhea
Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid
propulsion of intestinal contents through the small bowel results in diarrhea. Diarrhea is a hallmark
sign of gastroenteritis.
Assessment
Patient may manifest
Hyperactive bowel sounds
Audible borborygmi
Passage of loose liquid watery stools for more than 3 times
Poor skin turgor
Dehydration
Dry lips and oral mucosa
Altered LOC
Pain
Stomach cramping
Nursing Diagnosis
Diarrhea
Outcomes
Patient will verbalize understanding of causative factors and rationale for treatment regimen.
Patient will reestablish and maintain normal pattern of bowel functioning AEB passage of
semi-solid stools
Nursing Interventions
Rationale
Establish rapport
To gain patients trust
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Assess general condition and vital signs
Auscultate abdomen
Discuss the different causative factors and
rationale for treatment regimen
Restrict solid food intake
Provide for changes in dietary intake
Limit caffeine and high-fiber foods and so as
fatty foods
Promote use of relaxation technique
Encourage oral fluid intake of fluids containing
electrolyte
Recommend products like yogurt and cultured
milk
Emphasize importance of handwashing
For baseline data
For presence, location, and characteristics of
bowel sounds
For patient education
To allow for bowel rest and reduce intestinal
workload
To preventfoods/substances that precipitate
diarrhea
To prevent gastric irritation
To decrease stress and anxiety that can
aggravate diarrhea
For fluid replacement
To restore normal flora
To prevent spread of infectious diseases
AcutePain
One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation,
the bodys immune response, causing the release of cytokine and prostaglandin causing an increase
in vascular permeability and causes pain, which felt by the patient in the abdomen.
Assessment
Patient may manifest
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Abdominal Pain
Appears weak
Limited range of motion
Restlessness
Verbalization of pain with a pain
Facial grimaces
Irritability
Impaired thought process
Reduced interaction with people
sleep disturbances
Diaphoresis
Nursing Diagnosis
Acute Pain
Outcomes
Patient will report a decrease of pain.
Patient will be free from pain and demonstrate relaxational skills.
Nursing Interventions
Review factor that aggravate or alleviate pain
Instruct the SO to massage the area where pain
is elicited if not contraindicated
Encourage pain reduction techniques
Rationale
To lessen/alleviate pain caused by various
factors (administer meds via IV push)
To reduce pain and promote relief/comfort
To promote healing and provide nonpharmacological pain reduction techniques
Provide adequate rest
To reduce pain and promote relief/comfort
Provide diversional activities like socialization
For clients comfort and relief from pain
Administer analgesics to maintain acceptable
level of pain if not contraindicated
For clients comfort and relief from pain
Instruct client to perform deep breathing
Deep breathing exercises may reduce pain
exercises (DBE)
sensation/ used in pain management
To promote timely intervention/ revision of
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Monitor effectiveness of pain medications
plan of care
DeficientFluidVolume
Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume
deficit. The body would want to expel the foreign objective as much as possible thus it doesnt
undergo its normal speed, with that, the digestive system organs are not able to absorb the excess
fluids that are usually absorbed by the body.
Assessment
Patient may manifest
passage of loose watery stool
vomiting
abdominal cramping
dehydration
nausea
fatigue
weakness
nervousness
confusion
weight loss
decreased skin turgor
decreased urine output
dry mucous membrane
fever
Nursing Diagnosis
Deficient fluid volume RT excessive losses through normal routes AEB frequent passage of
loose watery stool
Outcomes
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Patient will report understanding of causative factors for fluid volume deficit
Patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as
output, and normal skin turgor.
Nursing Interventions
Rationale
Maintain adequate hydration, increase fluid
To prevent dehydration & maintain hydration
intake.
status.
Provide frequent oral care
To prevent from dryness
Administer Intravenous fluids as prescribed
Determine effects of age.
Restrict solid food intake, as indicated
Discuss individual risk factors/ potential
problems and specific interventions
To deliver fluids accurately and at desired
rates.
Very young and extremely elderly individuals
are quickly affected by fluid volume deficit
To allow for bowel rest and to reduced
intestinal workload.
To prevent or limit occurrence of fluid deficit.
ActivityIntolerance
Activity intolerance is insufficient physiological or psychological energy poor endure or complete
required or desired daily activities. Because of low hgb and hct level there will be decrease oxygen
being delivered to the tissues of the body since the hgb is responsible for the oxygenation of tissue.
As a compensatory mechanism, the body will increase its demand of oxygen by increasing
respiratory rate of the patient which results then to fatigue. Because of this there will be fast
consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the
patient has muscle weakness there will be activity intolerance.
Assessment
Patient may manifest
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Weakness
Restlessness
Physical inactivity
Increase respiratory rate
Fatigue
Low hgb count
Low hct count
Nursing Diagnosis
Activity intolerance related to generalized weakness AEB limited physical activity.
Outcomes
Patient will identify negative factors affecting activity intolerance and eliminate or reduce their
effects.
Patient will participate willingly in necessary or desired activities.
Nursing Interventions
Provide health teaching on the client regarding
the organization and time management
technique to prevent while on activity
Provide enough air coming from the electric
fan or from the window
Develop and adjust simple activity like
brushing his teeth
Rationale
To enhance patient ability to participate in
activity
To monitor patients response to activities
To prevent overexertion
Assist client with activity
To protect patient from injury
Promote comfort measures on the activity
To prevent over-exhaustion
Cluster nursing care
To prevent over-exhaustion
Ascertain ability to stand and move about
degree of assistance
Encourage complete bed rest
To determine current status and needs
For patient recuperation and recovery
OtherPossibleNursingCarePlans
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Imbalanced Nutrition: Less than Body Requirements due to insufficient intake and excessive
output;
Risk for Deficient Fluid Volume (if diarrhea does not occur or intake of fluids is insufficient but
does not have any signs of dehydration);
Hyperthermia RT inflammatory process.
SeeAlso:
Nursing Care Plans
MattVera,RN
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MattVeraisaregisterednurseandoneofthemaineditorsforNurseslabs.com.Enjoyshealthtechnologyandinnovations
aboutnursingandmedicine,ingeneral.
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