NCP Diarrhea : Fluid and Electrolyte Imbalances and Risk for Impaired Skin Integrity

Diarrhea is the frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and cramps commonly referred to as gas.

Acute diarrhea, meaning diarrhea that is not long-term, is a very common cause death in developing nations, especially among young children and babies. It usually appears rapidly and may last from between five to ten days.

Chronic diarrhea, meaning long-term diarrhea is the second cause of death among children in developing countries.

The most significant cause of severe illness is loss of water and electrolytes. In diarrhea, fluid passes out of the body before it can be absorbed by the intestines. When the ability to drink fluids fast enough to compensate for the water loss because of diarrhea is impaired, dehydration can result. Most deaths from diarrhea occur in the very young and the elderly whose health may be put at risk from a moderate amount of dehydration.

Nursing Care Plan for Diarrhea

Nursing Diagnosis : Fluid and Electrolyte Imbalances related to fluid loss secondary to diarrhea

Goal: fluid and electrolyte balance is maintained to the fullest.

Expected outcomes:
  • Vital signs within normal limits
  • Elastic turgor, mucous membranes moist lips
  • Consistency soft bowel movements, frequency of 1 time per day.

Interventions and Rational:

1. Monitor signs and symptoms of fluid and electrolytes:
R / Decrease in circulating fluid volume causes mucosal dryness and urinary concentration. Early detection enables immediate fluid replacement therapy to correct the deficit.

2. Monitor intake and output
R / Dehydration may increase the glomerular filtration rate, making the output is not adequate to clear metabolic waste.

3. Measure your weight every day
R / Detecting fluid loss, a decrease of 1 kg equal to 1 ltr of fluid loss

4. Encourage the family to give the drink a lot on the client, 2-3 lt / day
R / Replace lost fluids and electrolytes orally.

Nursing Diagnosis : Risk for Impaired Skin Integrity related to an increase in the frequency of diarrhea.

Goal: no impaired skin integrity.

Expected outcomes:
  • Avoid irritation: redness, blisters, cleanliness maintained,
  • Families are able to demonstrate perianal care properly.

Intervention and Rational:

1. Discuss and explain the importance of keeping the bed:
R / Hygiene prevent the proliferation of germs.

2. Demonstrate and involve families in the treatment of perianal (when wet and dressed down as well as the base):
R / Prevent skin irritation is not expected because of the humidity and the stool acidity.

3. Adjust the position of sleeping or sitting with an interval of 2-3 hours:
R / Smooth vascularization, reducing the emphasis on time so did not happen ischemia and irritation.

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