Silahkan berkunjung keblog saya, semoga bermanfaat bagi kita semua dan dapat memajukan dunia keperawatan.

Nursing Diagnosis: Diarrhea Application of NANDA, NOC, NIC


Nursing Diagnosis: Diarrhea
Betty J. Ackley

NANDA Definition: Passage of loose, unformed stools

Defining Characteristics: Hyperactive bowel sounds; at least three loose liquid stools per day; urgency; abdominal pain; cramping

Related Factors:
Psychological
High stress levels and anxiety
Situational
Alcohol abuse; toxins; laxative abuse; radiation; tube feedings; adverse effects of medications; contaminants; travel
Physiological
Inflammation; malabsorption; infectious processes; irritation; parasites

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Bowel Elimination
·         Electrolyte and Acid-Base Balance
·         Fluid Balance
·         Hydration
·         Treatment Behavior: Illness or Injury
Client Outcomes
·         Defecates formed, soft stool every day to every third day
·         Maintains a rectal area free of irritation
·         States relief from cramping and less or no diarrhea
·         Explains cause of diarrhea and rationale for treatment
·         Maintains good skin turgor and weight at usual level
·         Contains stool appropriately (if previously incontinent)
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Diarrhea Management
Nursing Interventions and Rationales
·         Assess pattern of defecation or have client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. Assessment of defecation pattern will help direct treatment (Mertz et al, 1995; Hogan, 1998).
·         Identify cause of diarrhea if possible (e.g., viral, rotavirus, human immunodeficiency virus [HIV]); food; medication effect; radiation therapy; protein malnutrition; laxative abuse; stress). See Related Factors (r/t). Identification of the underlying cause is imperative because the treatment and expected outcome depend on it. If the onset of diarrhea is sudden with no obvious cause, a colonoscopy is recommended to rule out colon cancer. When reviewing medication, assess for medications that increase peristalsis, such as metoclopramide (Reglan). HIV infection is also commonly associated with diarrhea (Anastasi, 1993).
·         If client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, consider possibility of Clostridium difficile infection. C. difficile infection and pseudomembranous colitis have become increasingly common because of the frequent use of broad-spectrum antibiotics (Vogel, 1995; Gantz, Gerding, Johnson, 1998).
·         Use Standard Precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing. C. difficile has been shown to be contagious and at times epidemic. One study of medical patients demonstrated that more than 30% developed nosocomial diarrhea after admission to a nursing unit, and the majority of cases were caused by C. difficile (McFarland, 1995). C. difficile is spread by direct or indirect contact, placing other clients at risk for infection (Miller, Walton, Tordecilla, 1998).
·         Obtain stool specimens as ordered to either rule out or diagnose an infectious process (e.g., ova and parasites, C. difficile infection, bacterial cultures).
·         If client has infectious diarrhea, avoid using medications that slow peristalsis. If an infectious process is occurring, such as C. difficile infection or food poisoning, medication to slow down peristalsis should generally not be given (Bliss et al, 2000). The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon (Gantz, Gerding, Johnson, 1998).
·         Observe and record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output. Documentation of output provides a baseline and helps direct replacement fluid therapy.
·         Inspect, palpate, percuss, and auscultate abdomen; note whether bowel sounds are frequent.
·         Assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness (Hogan, 1998) and cause death in the very young, the chronically ill, and the elderly.
·         Observe for symptoms of sodium and potassium loss (e.g., weakness, abdominal or leg cramping, dysrhythmia). Note results of electrolyte laboratory studies. Stool contains electrolytes; excessive diarrhea causes electrolyte abnormalities that can be especially harmful to clients with existing medical conditions.
·         Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure specific gravity of urine if possible. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume.
·         Weigh client daily and note decreased weight. An accurate daily weight is an important indicator of fluid balance in the body (Metheny, 2000).
·         Give clear fluids as tolerated (e.g., clear soda, Jell-O), serving at lukewarm temperature.
·         For children with diarrhea, give oral rehydration therapy liquids (Pedialyte) as directed by physician. Oral rehydration therapy is effective for treating mild to moderate dehydration in children with diarrhea and may help prevent the need for hospitalization with administration of IVs (Larson, 2000).
·         If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea. The loss of proteins, electroytes, and water from diarrhea in a cancer client can lead to rapid deterioration and possibly fatal dehydration (Kornblau et al, 2000)
·         If diarrhea is chronic and there is evidence of malnutrition, consult with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. A hydrolyzed formula contains protein that is partially broken down to small peptides or amino acids for people who cannot digest nutrients (Cataldo, DeBruyne, Whitney, 1999).
·         Encourage client to eat small, frequent meals and to consume foods that normally cause constipation and are easy to digest (e.g., bananas, crackers, pretzels, rice, potatoes, applesauce). Encourage client to avoid milk products, foods high in fiber, and caffeine (dark sodas, tea, coffee, chocolate). Bland, starchy foods are initially recommended when starting to eat solid food again (Rice, 1994).
·         Provide a readily available bedpan, commode, or bathroom.
·         Maintain perirectal skin integrity. Cleanse with a mild cleansing agent (perineal skin cleanser). Apply protective ointment prn. If skin is still excoriated and desquamated, apply a wound hydrogel. Avoid the use of rectal Foley catheters. Moisture-barrier ointments protect the skin from excoriation. Rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture, and the nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care (Bosley, 1994; Fiers, 1996).
·         If client is receiving a tube feeding, do not assume it is the cause of diarrhea. Perform a complete assessment to rule out other causes such as medication effects, sorbitol in medications, or an infection. Research has shown that tube feedings do not usually cause diarrhea (Campbell, 1994). Howeve, sorbitol in medication has been linked to diarrhea (Drug Watch, 1994).
·         If client is receiving a tube feeding, suggest formulas that contain a bulking agent such as Jevity. Note rate of infusion, and prevent contamination of feeding by rinsing container every 8 hours and replacing it every 24 hours. Rapid administration of tube feeding and contaminated feedings have been associated with diarrhea. Bulking agents are useful in tube feedings to prevent diarrhea (Doughty, 1991; Bockus, 1993).
Geriatric
·         Evaluate medications client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, ACE inhibitors, Hx-receptor antagonists, NSAIDS, anticholinergic agents, oral hypoglycemia agents, antibiotics, and others. A drug-associated cause should always be considered when treating diarrhea in the older person; many drugs can result in diarrhea (Ratnaike, 2000).
·         Monitor client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered. Impactions are more common in the elderly than in younger clients. It is very important that the client be checked for impaction before being given any antidiarrheal medication (Carnaveli, Patrick, 1993).
·         Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if client has symptoms of dehydration or electrolyte disturbances such as lassitude, weakness, or prostration. Elderly clients can dehydrate rapidly. The greatest concern for elderly clients with severe diarrhea is hypokalemia. Hypokalemia is treatable but when missed can be fatal (Carnaveli, Patrick, 1993).
·         Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea. Diarrhea can be a great source of embarrassment to the elderly and can lead to social isolation and a feeling of powerlessness (Carnaveli, Patrick, 1993).
Home Care Interventions
·         Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.
·         Assess for methods of handling soiled laundry if client is bedbound or has been incontinent. Instruct or reinforce Standard Precautions with family and bloodborne pathogen precautions with agency caregivers. The Bloodborne Pathogen Regulations of the Occupational Safety and Health Administration (OSHA) identify legal guidelines for caregivers.
·         When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-the-counter medications when self-treating. Mixing over-the-counter medications can further irritate the gastrointestinal system, intensifying the diarrhea or causing nausea and vomiting.
Client/Family Teaching
·         Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.
·         Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.
·         Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food).
·         Help client to determine stressors and set up an appropriate stress reduction plan.
·         Teach signs and symptoms of dehydration and electrolyte imbalance.

Tidak ada komentar: