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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
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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
Rationale
Establish rapport
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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
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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
exercises (DBE)
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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
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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
intake.
status.
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
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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
To prevent over-exhaustion
To prevent over-exhaustion
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
http://nurseslabs.com
MattVeraisaregisterednurseandoneofthemaineditorsforNurseslabs.com.Enjoyshealthtechnologyandinnovations
aboutnursingandmedicine,ingeneral.
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