HELEN B.

GONZALES

BSN- 3

NCM 112 RLE

NURSING CARE PLAN FOR CROHN’S DISEASE

DIARRHEA

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE DATA: PROBLEM IDENTIFIED: SHORT TERM OBJECTIVES: INDEPENDENT : SHORT TERM OBJECTIVES:
-  Promote bed rest and  Rest decreases
Vital signs: Diarrhea After 6 hours of nursing care, provide bedside intestinal motility and After 6 hours of nursing care,
patient will be able to re- commode. reduces the Patient was able to re-
BP: 165/95 mmHg NURSING DIAGNOTIC establish and maintain metabolic rate when establish and maintain
Pulse Rate: 69 bpm STATEMENT: normal bowel functioning. infection is a normal bowel functioning.
Respiratory Rate: 15 cpm complication.
 Patient’s history of Diarrhea related to gastro- LONG TERM ONJECTIVES:  Restrict food as  These foods can add LONG TERM OBJECTIVES:
portion of small intestinal inflammation as - indicated like foods more irritation to the
bowel resected 5 evidenced by abdominal pain. After three days or until containing caffeine, stomach After three days or until
years ago discharges the patient will not too much oil, fiber, discharges the patient did not
(obstruction from CAUSE ANALYSIS: have an episode of loose milk and fruits  This will help experience an episode of
scarring and stricture) stool  Observe and record differentiate loose stool
 Appendectomy at the In people with Crohn’s stool frequency, individual disease and
age of 13 Disease, the digestive tract characteristics, assesses severity of
 Patient experience becomes inflamed even when amount, and episode
some mild fatigue there is not an infection. The precipitating factors.
 Mild arteriolar inflammation often leads to  Restart oral fluid  This will provide
narrowing exam symptoms such as diarrhea. intake gradually. colon rest by omitting
without Diarrhea can be one of the Often clear liquids or decreasing
hemorrhages, more unsettling and hourly, and avoid cold stimulus of foods or
exudates, or bothersome symptoms of fluids. fluids. Gradually
papilledema Crohn’s Disease consumption of
 Truncal obesity with ( healthline.com) liquids may prevent
 abdominal striae cramping and
 Soft abdomen, not Damaged intestinal wall recurrence of
distended, and tissue diarrhea. Cold fluids
without bruits Loss of ability to absorb can increase
 Guarding with water to be excreted diarrhea intestinal motility.
pressure to right  Observe for the  This will help to
lower quadrant presence of assess the causative
 Hyperactive bowel associated factors factors and etiology.
sounds such as abdominal
 No perineal lesions or pain. Bloody stools,
intestinal mass cramping or
 Stool is heme emotional upset.
negative  Educate the patient  The anal area should
about the perineal be gently after a
care after each bowel bowel movement to
movement prevent skin irritation
and transmission of
microorganism
 Identify foods and  Avoiding intestinal
fluids that precipitate irritants promotes
diarrhea intestinal rest

DEPENDENT:
 Take anti-diarrheal  Decrease GI motility
medications as or peristalsis and
prescribes. diminishes digestive
cramping and
diarrhea. These drugs
coat the intestinal
wall and absorb
bacterial toxins

COLLABORATIVE:
  Submit client’s stool  A culture is a test to
for culture. detect which
causative organisms
cause an infection.
 Encourage patient to  When a client
eat foods rich in experience a
potassium as diarrhea, the stomach
prescribed by the contents which is
nutritionist high in potassium get
flushed out of the
gastrointestinal tract
into the stool and out
of the body, resulting
in hypokalemia

ACUTE PAIN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE DATA: PROBLEM IDENTIFIED: SHORT TERM OBJECTIVES: INDEPENDENT: SHORT TERM OBJECTIVES:
 Provide measures to  It is preferable to
Vital signs: Abdominal pain After 6 hours of nursing care, relive pain before it provide an analgesic After 6 hours of nursing care,
the patient will verbalized becomes severe before the onset of the patient verbalized
BP: 165/95 mmHg NURING DIAGNOSTIC reduction of pain from a pain pain or before it reduction of pain from a pain
Pulse Rate: 69 bpm STATEMENT: scale of 4 in q 0-10 scale with becomes severe scale of 4 in q 0-10 scale with
Respiratory Rate: 15 cpm 10 as the most painful when a larger dose 10 as the most painful
Acute pain related to may be required
 Patient’s history of inflammation LONG TERM ONJECTIVES:  Acknowledge and  Nurses have the duty
portion of small accept the client’s to ask their pain and
bowel resected 5 CAUSE ANALYSIS: After three days or until pain believe their reports
years ago discharge of the patient will of pain. Challenging
(obstruction from Intermittent, partial small demonstrate ways to reduce or undermining their
scarring and stricture) bowel obstruction in Crohn’s pain pain reports in an
 Appendectomy at the disease can frequently cause unhealthy
 age of 13 pain ( Docherty, M. 2011) therapeutic
 Patient experience relationship
some mild fatigue  Determine and  Acute pain is that
 Mild arteriolar document presence which follows or
narrowing exam of possible occurs suddenly with
without pathophysiological onset of painful
hemorrhages, and psychological condition (Crohn’s
exudates, or causes of pain (e.g. disease)
papilledema inflammation or
 Truncal obesity with infections)
abdominal striae  Assess for referred  To help determine
 Soft abdomen, not pain as appropriate possibility of
distended, and underlying condition
without bruits or organ dysfunction
 Guarding with requiring treatment
pressure to right  Evaluate pain  Use pain rating scale
lower quadrant characteristics and appropriate for age
 Hyperactive bowel intensity and cognition (0-10
sounds scale)
 No perineal lesions or  Perform pain  This demonstrates in
intestinal mass assessment each time status or to identify
 Appropriate strength pain occurs. worsening of
and ROM Document and underlying
 No femoral bruits investigate changes condition/developing
from previous reports complications
and evaluate results
of pain intervention
 Provide comfort  To promote non
measures and calm pharmacological pain
activities management
 Instruct and  To prevent fatigue
encourage use of
relaxation techniques
 Perform proper  Appropriate
 nursing interventions measures if best to
and appropriate prevent
procedures to complications
alleviate pain
DEPENDENT:
 Take analgesics, as  To maintain
indicated, to “acceptable” level of
maximum dosage as pain notify physician
needed if regimen is
inadequate to meet
pain control goal.
Combinations may be
used on prescribed
COLLABORATIVE: intervals
 Evaluate laboratory  To check for any
results imbalances

DEFICIENT FLUID VOLUME

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE DATA: PROBLRM IDENTIFIED: SHORT TERM OBJECTIVES : INDEPENDENT:
-  Monitor and record  These changes in vital
Vital signs: Dehydration After 6 hours of nursing vital signs signs are associated
interventions, patient will: with fluid volume loss
BP: 165/95 mmHg NURSING DIAGNOSIS  Able to exhibit moist  Observe or measure  Note the color. May
Pulse rate: 69 bpm STATEMENT: mucous membrane urinary output be dark greenish
Respiratory rate: 15 cpm and good skin turgor brown because of
Deficient fluid volume related concentration
 Warm and dry skin to active fluid volume loss as LONG TERM OBJECTIVES:  Adequate rest and  To avoid exhausting
with flakiness evidenced by poor skin turgor - sleep should be the patient, this may
 Poor skin turgor and dry mucous membrane After three days or discharge, provided lead more on fluid
 Patient experience the patient will: loss
some mild fatigue CAUSE ANALYSIS:  Maintain fluid volume  Provide proper  To avoid other fluid
 at a functional level ventilation and cool loses through
Fluid volume deficit or demonstrate environment excessive sweating
hypovolemia occurs from a behaviors to monitor  Provide frequent orall  To limit gastric or
loss of body fluid or the shift and correct deficit, as as well as eye care intestinal losses
of fluids into the third space, indicated  Assess skin turgoe,  Fluid loss occurs first
or from a reduced fluid mucous membrane in extracellular
intake. Common sources for every shift spaces, resulting in
fluid loss are the poor skin turgor and
gastrointestinal (GI) tract. dry mucous
DEPENDENT: membrane
 Changes position  To reduce pressure
frequently on fragile skin and
tissues
 Take medications as  To prevent injury
prescribe from dryness

COLLABORATIVE:
 Review laboratory  This will be used to
data evaluate the body’s
response to fluid loss
and to determine
replacement needs.
 IVF administered as  To deliver fluids
ordered. Maintain at accurately at desired
proper regulation rates

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain may be related to After 4 hours of nursing INDEPENDENT: After 4 hours of nursing
hyperperistalsis, prolonged interventions, the patient will  Encourage client to  May try to tolerate interventions, the patient was
“madalas sumasakit ang tiyan diarrhea, skin and tissue report pain is relieved or report pain. pain rather than able to report pain is relieved
ko at madalas ang pagdumi irritation, perirectal controlled and appear to be request analgesics. or controlled and appear to
ko” as verbalized by the excoriation, fissures, and relaxed and able to sleep and  Assess reports of  Changes in pain be relaxed and able to sleep
patient. fistulas. rest appropriately. abdominal cramping characteristics may and rest appropriately.
 or pain, noting indicate spread of
OBJECTIVE: location, duration, disease or developing
and intensity. complications.
 Reluctance to move  Review factors that  May pinpoint
 Abdominal guarding aggravate or alleviate precipitating or
restlessness pain. aggravating factors
 V/S taken as follows: such as stressful
events, food
T: 37.1°C intolerance, or
P: 75 identify developing
R: 18 factors.
BP: 110/80  Encourage patient to  Reduces abdominal
assume position of tension and promotes
comfort, such as sense of control.
knees flexed.
 Provide comfort  Promotes relaxation,
measures and refocuses attention,
diversional activities. and may enhance
coping abilities.
 Cleanse rectal area  Protects skin from
with mild soap and bowel acids,
water after each stool preventing
and provide skin care excoriation.
with moisture barrier
ointment.
 Provide sitz bath, as  Enhances cleanliness
appropriate. and comfort in the
presence of perianal
irritation and fissures.
 Observe and record  May indicate
abdominal distention. developing intestinal
obstruction from
inflammation, edema,
and scarring.
 Collaborative:
 Implement prescribed  Complete bowel rest
dietary modifications can reduce pain and
such as commence cramping.
with liquids and
increase to solid
foods as tolerated.
 Administer analgesics  Pain varies from mild
as indicated. to severe and
necessitates
management to
facilitate adequate
rest and recovery.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Problem identified: Short term:  Provide a quiet, calm,  Establishing a trusting Short term:
Anxiety after 6 hours of nursing and safe environment environment after 6 hours of nursing
“madalas sumasakit ang tiyan intervention, for the patient. between the patient intervention,
ko at madalas ang pagdumi Nursing Diagnosis: Anxiety  The patient will  Explain the risk and the nurse creates  The patient was able
ko” as verbalized by the related to change in health express awareness of factors and other an open and to express awareness
patient. status secondary to Crohn’s the anxiety and ways important harmonious of the anxiety and
disease as evidenced by to cope and deal with information regarding relationship. ways to cope and
OBJECTIVE: restlessness and verbalization it. Crohn’s disease.  Providing a good deal with it.
of concern regarding current  The patient will Allow the client to explanation of the  The patient was able
 Reluctance to move changes in the patient’s life. present calm and have enough time to information about to present calm and
 Abdominal guarding verbalize reduced think and ask Crohn’s disease can verbalizes reduced
restlessness anxiety level. questions. help alleviate anxiety. anxiety level.
 V/S taken as follows:  Teach the patient to Also, providing an
perform deep opportunity for the
T: 37.1°C breathing by standing client to ask
P: 75 in front of the patient questions can help
R: 18 and doing it reduce anxiety levels.
BP: 110/80 simultaneously.  Restless patients may
 Assess the patient’s not follow directions
anxiety level and easily, deep breathing
perspective of the can help the patient
situation by asking calm down during
open-ended acute anxiety attacks.
questions in a calm  These can help the
and non-threatening nurse explore the
manner. patient’s thoughts
 Educate the patient and feelings. The
about the disease patient can honestly
process, management communicate if they
of symptoms, feel comfortable and
resources available, secure.
and how to avoid  Giving adequate
exacerbations. information about
Explain this briefly the disease process
while evaluating the can help the patient
patient’s understand that the
understanding and condition can be
concerns. managed, lessening
 Encourage the anxiety. Simple
patient to share fears discussion can help
and concerns the patient cope with
regarding the the situation.
condition.  The nurse can offer
Acknowledge the specific options for
patient’s feelings and the patient when the
discuss options that nurse knows the
might help. exact concern of the
 Educate the patient patient.
about relaxation  These can help the
techniques and patient cope with the
diversional activities condition providing
such as guided relief during anxiety
 imagery, meditation, attacks.
exercise, etc.  Involving the patient
 Make a treatment in the treatment
plan with the patient planning will help the
involving them in the patient gain control
decision-making. over their condition,
 Refer the patient to a increasing
support group or compliance.
psychotherapy upon  The patient can gain a
consent. sense of
belongingness to
individuals with the
same problems and
teach them effective
coping strategies.

NURSING CARE PLAN FOR ULCERATIVE COLITIS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to Short term goal INDEPENDENT NURSING After 6 hours of nursing
“ subrang sakit po ng tiyan ko prolonged diarrhea. ACTION: intervention the patient was
kanina pa po ako labas masok After 6 hours of nursing  Encourage patient to  May try to tolerate able to relaxed and rest
sa CR” as verbalized by the intervention the patient will report pain. pain rather than appropriately
patient. be able to relaxed and rest request analgesics.
appropriately  Assess reports of  To measure the
OBJECTIVE: abdominal cramping intensity of pain and
or pain, nothing to know what
 Fatigue location, duration, management should
 Weight loss intensity (0-10 scale). be given.
 Hyper action Investigate and
Bowel sounds report changes in
pain characteristics
Vital signs:  Note nonverbal cues.  Body language or
HR:110bpm Investigate nonverbal cues may
RR: 19BPM discrepancies be both physiological
BP: 90/60 mmHg between verbal and and psychological and
Temperature: 38.1°c nonverbal cues. may be used in
conjunction with
Physical assessment: verbal cues to
 Pallor determine extent and
 Abdominal pain severity of the
tenderness problem.
 Panniculitis  Review factors that  May pinpoint
aggravate or alleviate precipitating or
pain. aggravating factors
identify developing
complications.
 Encourage patient to  Reduces abdominal
assume position of tension and promotes
comfort. sense of control.
 Provide comfort  Promotes relaxation,
measures and refocuses attention,
diversional activities. and may enhance
coping abilities.
 Observe and record  May indicate
abdominal distention, developing intestinal
increased obstruction from
temperature, inflammation, edema,
decreased BP. and scarring.

DEPENDENT NURSING
ACTION:
 Provide additional  Maintain of bowel
fluids via IV as rest requires
ordered by the alternative fluid
physician. replacement to
correct losses and
 anemia.
 Administer  A better choice of
medication like pain relief is
acetaminophen as acetaminophen for
ordered by the ulcerative colitis.
physician

COLLABORATIVE NURSING
ACTION
 Coordinate with a  To prevent imbalance
dietary counselor for nutrition and to
meal planning regain the loss
modifications nutrients due to
diarrhea.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Diarrhea related to Short term goal:  Commence a stool  To monitor the Short term goal:
“ subrang sakit po ng tiyan ko inflammation of bowel as chart. Use a patient’s bowel
kanina pa po ako labas masok evidenced by loose, watery After 6 hours of nursing standardized stool pattern. After 6 hours of nursing
sa CR” as verbalized by the stools, abdominal cramping intervention, the patient will assessment tool such intervention, the patient Was
patient. and pain, increased urgency be able to return to a more as Bristol stool chart. able to return to a more
to defecate, tenesmus, and normal stool consistency and  Administer  To help decrease the normal stool consistency and
OBJECTIVE: increased bowel sounds frequency. medications for frequency of stools frequency.
ulcerative colitis as and alleviate
 Fatigue prescribed. diarrhea, the doctor
 Weight loss may prescribe: Anti-
 Hyper action inflammatory drugs-
Bowel sounds first line of treatment
for people with
Vital signs: ulcerative colitis
HR:110bpm Immune system
RR: 19BPM suppressors- work by
BP: 90/60 mmHg prohibiting
Temperature: 38.1°c inflammatory
response through
Physical assessment: suppressing the
 Pallor immune system
 Abdominal pain Biologics- work by
tenderness stopping proteins in
 Panniculitis the body from
causing inflammation
Anti-diarrheas and
antispasmodics
 Encourage to increase  To help ensure that
oral fluid intake as the patient will not
tolerated, ideally at have dehydration due
least 2L per day. to severe diarrhea.
Avoid cold drinks. Cold drinks can
Check if the patient is increase intestinal
in any fluid restriction motility.
before doing so.
 Help the patient to  To relieve abdominal
select appropriate pain and cramping,
dietary choices to alleviate diarrhea,
reduce the intake of and to promote
milk products, healthy food habits.
caffeinated drinks, To avoid flare ups of
alcohol and avoid ulcerative colitis. High
high fiber, high fat fiber and high fat
foods. foods can cause
irritation in the
intestines.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:   Imbalanced Nutrition: Less Short term goal: INDEPENDENT:  A record of the Short term goal:
“ subrang sakit po ng tiyan ko than Body  Weigh the patient patient’s weight will
kanina pa po ako labas masok Requirements related to After 6 hours of nursing daily and document help assess the After 6 hours of nursing
sa CR” as verbalized by the altered absorption of intervention, the patient will readings. Record the progress of intervention, the patient was
patient. nutrients secondary to demonstrate adequate patient’s choices of treatment. Creating a able to demonstrate
Ulcerative colitis, as nutritional intake and meet food and drinks. food diary can help adequate nutritional intake
OBJECTIVE: evidenced by diarrhea, metabolic needs as evidenced monitor patient’s and meet metabolic needs as
abdominal pain and by weight gain. progress, as well as evidenced by weight gain.
 Fatigue cramping, weight loss, nausea his/her likes and
 Weight loss and vomiting, and loss of dislikes in terms of
 Hyper action appetite food and drinks.
Bowel sounds  Administering what
 Encourage family the patient likes to
Vital signs: members to bring eat can increase
HR:110bpm food from home. caloric intake and
RR: 19BPM promote weight gain.
BP: 90/60 mmHg Also, the participation
Temperature: 38.1°c of the family can
improve the patient’s
Physical assessment: appetite.
 Pallor  Burns can increase
 Abdominal pain  Document food the metabolic needs
tenderness intake and include of the body. It is
 Panniculitis caloric count. recommended that
an additional 40 kcal
must be given per
percentage of TBSA
burn in adults.
 The patient’s
 Promote a conducive environment can help
feeding environment. induce appetite and
promote the intake of
food.
 A clean mouth
  Educate the patient enhances the taste
about proper oral and promotes a good
hygiene. appetite.
 Dietitians can help in
 Refer the patient to a the assessment of the
dietitian and/or patient’s nutritional
nutritionist. status and nutritional
needs. They can also
recommend food to
support nutritional
gaps.
 In cases where the
 Administer throat has been
supplemental affected or any part
nutrition through the of the upper digestive
insertion of a system is impaired in
nasogastric tube or a burns patient,
the administration of supplemental
parenteral nutrition nutrition may be
as indicated by the necessary.
physician and as
recommended by the
dietitian team.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: PROBLEM IDENTIFIED : Short term goal: Independent : Short term goal:
“ subrang sakit po ng tiyan ko Ineffective Coping  Assess patient’s and  Enables the nurse to
kanina pa po ako labas masok After 6 hours of nursing SO’s understanding deal more realistically After 6 hours of nursing
sa CR” as verbalized by the intervention, and previous with current intervention,
patient.  Assess the current methods of dealing problems. Anxiety  Assessed the current
situation accurately. with the disease and other problems situation accurately.
OBJECTIVE:  Identify ineffective process. may have interfered  Identified ineffective
coping behaviors and with previous health coping behaviors and
  Fatigue consequences. teaching and patient consequences.
 Weight loss  Acknowledge own learning.  Acknowledged own
 Hyper action coping abilities.  Help patient identify  Use of previously coping abilities.
Bowel sounds  Demonstrate individually effective successful behaviors  Demonstrated
necessary lifestyle coping skills. can help a patient necessary lifestyle
Vital signs: changes to deal with the current changes to
HR:110bpm limit/prevent situation and plan for limit/prevent
RR: 19BPM recurrent episodes. the future. recurrent episodes.
BP: 90/60 mmHg  Provide  Exhaustion brought
Temperature: 38.1°c uninterrupted sleep on by the disease
and rest periods. tends to magnify
Physical assessment: problems, interfering
 Pallor with the ability to
 Abdominal pain cope.
tenderness  Encourage the use of  Refocuses attention,
 Panniculitis stress management promotes relaxation,
skills (relaxation and enhances coping
techniques, abilities.
visualization, guided
imagery, deep-
breathing exercises).
 Include patient and  Promotes continuity
SO in team of care and enables
conferences to patients and SO to
develop an feel a part of the
individualized plan, imparting a
program. sense of control and
increasing
cooperation with the
therapeutic regimen.
 Administer  Aids in psychological
medications as and physical rest.
indicated: antianxiety Conserves energy and
agents, such may strengthen
 as lorazepam (Ativan) coping abilities.
Alprazolam (Xanax).

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:  Acute Pain After 6 hours of nursing Independent: After 6 hours of nursing
“ subrang sakit po ng tiyan ko intervention, the patient will  Encourage the  May try to tolerate intervention, the patient was
kanina pa po ako labas masok able to: patient to report pain rather than able to:
sa CR” as verbalized by the  Report pain is pain. request analgesics.  Report pain was
patient. relieved/ controlled.  Assess abdominal  Colicky intermittent relieved/ controlled.
 Appear relaxed and cramping or pain pain occurs with  Appear relaxed and
OBJECTIVE: able to sleep/rest reports, noting Crohn’s disease able to sleep/rest
appropriately. location, duration, appropriately.
 Fatigue and intensity (0–10
 Weight loss scale). Investigate
 Hyper action and report changes in
Bowel sounds pain characteristics
 Note nonverbal cues  Body language or
Vital signs: (restlessness, nonverbal cues may
HR:110bpm reluctance to move, be both physiological
RR: 19BPM abdominal guarding, and psychological and
BP: 90/60 mmHg withdrawal, may be used in
Temperature: 38.1°c and depression). conjunction with
Investigate verbal cues to
Physical assessment: discrepancies determine the extent
 Pallor between verbal and and severity of the
 Abdominal pain nonverbal cues. problem.
tenderness  Review factors that  May pinpoint
 Panniculitis aggravate or alleviate precipitating or
pain. aggravating factors
(such as stressful
events, food
intolerance) or