FLORES

BSN-III A3
Possible and Probable Nursing Diagnosis for GIT Disorders

Nursing Diagnosis Interventions

Diarrhea related to: Ascertain onset and pattern of diarrhea
Inflammation, irritation, or malabsorption of the bowel Observe and record stool frequency, characteristics, amount, and precipitating
Presence of toxins factors.
Segmental narrowing of the lumen Observe for presence of associated factors, such as fever, chills, abdominal
pain,cramping, bloody stools, emotional upset, physical exertion and so forth.
Promote bedrest, provide bedside commode.
Remove stool promptly. Provide room deodorizers.
Identify and restrict foods and fluids that precipitate diarrhea (vegetables and
fruits, whole-grain cereals, condiments, carbonated drinks, milk products).
Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids.
Provide opportunity to vent frustrations related to disease process.
Observe for fever, tachycardia, lethargy, leukocytosis, decreased serum
protein,anxiety, and prostration.
Risk for Deficient Fluid Volume related to: Note possible conditions or processes that may lead to deficits such as fluid
Excessive losses through normal routes (severe frequent diarrhea, loss, limited intake, fluid shifts, environmental factor.
vomiting) Monitor I&O. Note number, character, and amount of stools; estimate
Hypermetabolic state (inflammation, fever) insensible fluid losses (diaphoresis). Measure urine specific gravity; observe
Restricted intake (nausea/anorexia) for oliguria.
Hemoconcentration; altered serum sodium Assess vital signs (BP, pulse, temperature).
Observe for excessively dry skin and mucous membranes, decreased skin
turgor, slowed capillary refill.
Weigh daily.
Maintain oral restrictions, bedrest; avoid exertion.
Observe for overt bleeding and test stool daily for occult blood.
Note generalized muscle weakness or cardiac dysrhythmias.
Administer parenteral fluids, blood transfusions as indicated.
Monitor laboratory studies such as electrolytes (especially potassium,
magnesium) and ABGs (acid-base balance).
Anxiety related to: Review physiological factors, such as active medical condition; recent or
Physiological factors/sympathetic stimulation (inflammatory process) ongoing stressors.
Threat to self-concept (perceived or actual) Observe and note behavioral clues (restlessness, irritability, withdrawal,
Threat to/change in health status, socioeconomic status, role lack of eye contact, demanding behavior).
functioning, interaction patterns Encourage verbalization of feelings. Provide feedback.
Acknowledge that the anxiety and problems are similar to those expressed
by others. Active-Listen patient’s concerns.
 Provide accurate, concrete information about what is being done (reason
for bedrest, restriction of oral intake, and procedures).
Provide a calm, restful environment.
Encourage staff and SO to project caring, concerned attitude.
Help patient identify and initiate positive coping behaviors used in the past.
Assist patient to learn new coping mechanisms (stress management
techniques, organizational skills).
Acute Pain related to: Encourage patient to report pain.
Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal Assess reports of abdominal cramping or pain, noting location, duration,
excoriation, fissures, fistulas intensity (0–10 scale). Investigate and report changes in pain characteristics
Note nonverbal cues (restlessness, reluctance to move, abdominal guarding,
withdrawal, and depression). Investigate discrepancies between verbal and
nonverbal cues.
Review factors that aggravate or alleviate pain.
Encourage patient to assume position of comfort (knees flexed).
Provide comfort measures (back rub, reposition) and diversional activities.
Cleanse rectal area with mild soap and water or wipes after each stool and
provide skin care (A&D ointment, Sween ointment, karaya gel, Desitin,
petroleum jelly).
Provide sitz bath as appropriate.
Observe for ischiorectal and perianal fistulas.
Observe and record abdominal distension, increased temperature, decreased
BP.
Implement prescribed dietary modifications (commence with liquids and
increase to solid foods as tolerated).
Ineffective Coping related to: Assess patient’s and SO’s understanding and previous methods of dealing with
Multiple stressors, repeated over period of time; situational crisis disease process.
Unpredictable nature of disease process Determine outside stressors (family, relationships, social or work
Personal vulnerability; inadequate coping method; lack of support environment).
systems Provide opportunity for patient to discuss how illness has affected relationship,
Severe pain including sexual concerns.
Lack of sleep, rest Help patient identify individually effective coping skills.
Provide emotional support:Active-Listen in a nonjudgmental manner;Maintain
nonjudgmental body language when caring for patient;Assign same staff as
much as possible.
Provide uninterrupted sleep and rest periods.
Encourage use of stress management skills, (relaxation techniques,
visualization, guided imagery, deep-breathing exercises).
Include patient and SO in team conferences to develop individualized
program.
Administer medications as indicated: antianxiety agents, such as lorazepam
 (Ativan), alprazolam (Xanax).
Refer to resources as indicated (local support group, social worker, psychiatric
clinical nurse specialist, spiritual advisor).
Imbalanced Nutrition: Less Than Body Requirements related to: Weigh daily.
Altered absorption of nutrients Encourage bedrest and limited activity during acute phase of illness.
Hypermetabolic state Recommend rest before meals.
Medically restricted intake; fear that eating may cause diarrhea Provide oral hygiene.
Serve foods in well-ventilated, pleasant surroundings, with unhurried
atmosphere, congenial company.
Avoid or limit foods that might cause or exacerbate abdominal cramping,
flatulence (milk products, foods high in fiber or fat, alcohol, caffeinated
beverages, chocolate, peppermint, tomatoes, orange juice).
Record intake and changes in symptomatology.
Promote patient participation in dietary planning as possible.
Encourage patient to verbalize feelings concerning resumption of diet.
Keep patient NPO as indicated.
Resume or advance diet as indicated (clear liquids progressing to bland, low
residue; then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber
as indicated).
Deficient Knowledge related to: Determine patient’s perception of disease process.
Information misinterpretation, lack of recall
Unfamiliarity with resources Review disease process, cause and effect relationship of factors that
precipitate symptoms, and identify ways to reduce contributing factors.
Encourage questions.
Review medications, purpose, frequency, dosage, and possible side
effects.
Remind patient to observe for side effects if steroids are given on a
long-term basis (ulcers, facial edema, muscle weakness).
Stress importance of good skin care (proper handwashing techniques
and perineal skin care).
Recommend cessation of smoking.
Emphasize need for long-term follow-up and periodic reevaluation.
Identify appropriate community resources [Crohn’s and Colitis
Foundation of America, (CCFA), United Ostomy Association, home
healthcare providers or visiting nurse services, dietitian, and social
services.
Reference: Matt Vera, RN. "7 Inflammatory Bowel Disease (IBD) Nursing Care Plans - Nurseslabs". Nurseslabs. N.p., 2013. Web. 23 Oct. 2016.