Nursing Diagnosis

Assessment Data Nursing Diagnosis Client goal Nursing Interventions Evaluation

Mustard /bloody Fluid volume deficit The child will have a  Assess patient vital signs and Client is adequately
vomitus watery related to excessive fluid balanced electrolyte, input, hydration status 2 hourly Assess hydrated and
stool, slow skin loss secondary to output status accompanied the child for signs of dehydration. maintaining appropriate
turgor and watery (intussusception) as by absence of vomiting and fluid intake as evidence
stool evidence by mustard diarreah. Rationale: Dehydration can result from by skin turgor brisk
mucous /bloody vomitus watery vomiting due to intussusception. The moist mucous
membranes dry stool, slow skin turgor appearance of mucous membranes, the membranes skin turgor
decreased urinary dry skin and watery stool quality of skin turgor, and the any increase brisk.
output lethargic dry mucous membranes in heart rate and decrease in blood
lethargic, decreased pressure levels should be assessed.
urinary output .
 Commence a strict fluid balance
charting and monitor input and
output of the patient.

Rationale: To monitor patient’s fluid

volume accurately. To check for any
worsening of intestinal blockage, such as
presence of blood in the stool.

 Monitor stool characteristics using

stool chart

Rationale: Initially, a child with

intussusception may pass a normal stool,
but later on, a mucus, blood-filled or jelly-
like stool is observed.

 Start intravenous therapy as

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 prescribed. Encourage oral intake.

Rationale: To replenish the fluids

and electrolytes lost from vomiting
or other gastric losses, and to
promote better blood circulation
around the body.

 Educate the child’s guardian on

how to fill out a fluid balance chart
at bedside. Inform the guardian the
need to start with clear fluids and
gradually going to soft diet.

Rationale: To help the guardian take

ownership of the patient’s care,
encouraging them to help the child
drink more clear fluids and then
gradually improving to soft diet. This
will also empower them to report any
changes to the nursing team.

 Weigh patient daily.

Rationale: To monitor any weaight

loss or gain

 Administer antiemetic’s as
prescribed.

Rationale: Antiemetics are medications

aimed at preventing or treating nausea and
vomiting
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Weight 5.9kg Imbalance nutrition less Client will maintain  Assess patient nutritional status Client has returned to
( underweight ) than body requirements weight/demonstrate and intake. normal diet post-
loss of appetite/ related to inability to progressive weight gain Rationale: Identifies deficiencies/needs to surgery and increased
NPO ,excessive ingest food and altered toward the goal with aid in the choice of interventions. nutrient intake as
mustard vomitus, absorption of nutrients normalization of laboratory  Create a daily weight chart and a evidence by regained
blood tinged secondary to values and be free of signs food and fluid chart. appetite, feeding orally
watery stool. intussusception as of malnutrition. Rationale: A record of the patient’s maintaining body
evidence by mustard weight will help assess the progress of weight.
vomitus, bloody watery treatment. Creating a food diary can help
stool, loss of monitor patient’s progress, as well as
appetite/NPO, weight his/her likes and dislikes in terms of food
loss. and drinks.
 Collaborate with dietitian to help
make appropriate dietary decisions
for patient.
Rationale: A dietitian can help the
medical team assess the patient’s
nutritional status and recommend food
options that will supplement the patient’s
nutritional gaps.
 Administer antidiarreah and
antiemetics as prescribed
Rationale: These drugs are used to slow
down or stop loose stools ( diarrhea ).
Facial grimacing, Altered comfort (Pain) Client will demonstrate Client demonstrated
irritability related to intestinal relief of pain on  Administer analgesic as prescribed relief of pain after
obstruction as evidence assessment for 8 hr shift. ( Paracetamol) nursing interventions as
by facial grimace on Rationale: Weight-adjusted analgesics evidence by nil facial
palpation and irritability. is administered intravenously post grimacing, increased
abdominal surgery. Once the patient is play activity smiling on
suited for an oral diet, oral opioid re-assessment.
analgesics can be given as prescribed.

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  Assess the patient vital signs and
characteristics of pain at least 30
minutes after administration of
medication.

Rationale: To monitor effectiveness

of medical treatment for the relief of
post-operative pain. The time of
monitoring of vital signs may depend
on the peak time of the drug
administered.

 Teach accompanying parent how

to use non pharmacological
interventions to help relief pain
such as positioning, distraction,
music therapy.

Rationale: To reduce stress levels,

thereby relieving the acute post-
operative pain.

 Gradually introduce oral fluids and

food as recommended by the
surgeon post-operatively.

Rationale: To allow the patient’s abdomen

to heal post-operatively, as the normal
bowel function gradually becomes
established.
Hemicolectomy, Risk for infection related Client will remain free of  Assess and monitor patient vital Client remained free

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ileostomy stoma to invasive procedure and infection throughout signs. from infection as
presence of stoma hospital. Rationale: Vital signs monitoring evidenced by the
(ileostomy, including the patient’s temperature absence of fever and
hemicolectomy) help in the monitoring of possible clear stoma.
infections.
 Regularly assess the patient’s
stoma and surrounding skin for
colour, exudates, erythema and
crusting lesions. Provide regular
stoma care.
Rationale: Regular stoma care
prevents infection and helps maintain a
clear, patent airway.

 Educate parent of the importance

of stoma care and proper hand
hygiene.
Rationale: Proper hand hygiene is
important to prevent the spread of harmful
infection causing bacteria.

 Keep affected area cover with a

paper or other forms of barrier.

Rationale: Providing a protective barrier

keeps the area safe by prevent tugging and
pulling of stoma bags by infant.

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