Definition
Gastroenteritis is 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).
Nursing Care Plans
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 patient’s trust |
| Assess general condition and vital signs | For baseline data |
| Auscultate abdomen | For presence, location, and characteristics of bowel sounds |
| Discuss the different causative factors and rationale for treatment regimen | For patient education |
| Restrict solid food intake | To allow for bowel rest and reduce intestinal workload |
| Provide for changes in dietary intake | To prevent foods/substances that precipitate diarrhea |
| Limit caffeine and high-fiber foods and so as fatty foods | To prevent gastric irritation |
| Promote use of relaxation technique | To decrease stress and anxiety that can aggravate diarrhea |
| Encourage oral fluid intake of fluids containing electrolyte | For fluid replacement |
| Recommend products like yogurt and cultured milk | To restore normal flora |
| Emphasize importance of handwashing | To prevent spread of infectious diseases |
Acute Pain
One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the body’s 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
- 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 | Rationale |
|---|---|
| Review factor that aggravate or alleviate pain | To lessen/alleviate pain caused by various factors (administer meds via IV push) |
| Instruct the SO to massage the area where pain is elicited if not contraindicated | To reduce pain and promote relief/comfort |
| Encourage pain reduction techniques | To promote healing and provide non-pharmacological pain reduction techniques |
| Provide adequate rest | To reduce pain and promote relief/comfort |
| Provide diversional activities like socialization | For client’s comfort and relief from pain |
| Administer analgesics to maintain acceptable level of pain if not contraindicated | For client’s comfort and relief from pain |
| Instruct client to perform deep breathing exercises (DBE) | Deep breathing exercises may reduce pain sensation/ used in pain management |
| Monitor effectiveness of pain medications | To promote timely intervention/ revision of plan of care |
Deficient Fluid Volume
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 doesn’t 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
- 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 intake. | To prevent dehydration & maintain hydration status. |
| Provide frequent oral care | To prevent from dryness |
| Administer Intravenous fluids as prescribed | To deliver fluids accurately and at desired rates. |
| Determine effects of age. | Very young and extremely elderly individuals are quickly affected by fluid volume deficit |
| Restrict solid food intake, as indicated | To allow for bowel rest and to reduced intestinal workload. |
| Discuss individual risk factors/ potential problems and specific interventions | To prevent or limit occurrence of fluid deficit. |
Activity Intolerance
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
- 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 | Rationale |
|---|---|
| Provide health teaching on the client regarding the organization and time management technique to prevent while on activity | To enhance patient ability to participate in activity |
| Provide enough air coming from the electric fan or from the window | To monitor patients response to activities |
| Develop and adjust simple activity like brushing his teeth | 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 | To determine current status and needs |
| Encourage complete bed rest | For patient recuperation and recovery |
Other Possible Nursing Care Plans
- 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.
