Student Name:

Patient Initials & Room # Dates of Care:

NANDA Lable #2 Diarrhea

Diarrhea r/t adverse effects of medications 2º Decubitis Flap Surgery AEB breakdown of anal skin integrity,
Nursing Diagnosis incontinence, at least three loose liquid stools per day, and client stating that "this is not a normal pattern for
me"
Medication Response
NOC:
Therapeutic and adverse effects of prescribed medication
Patient Desired Long Patient will experience therapeutic effects from medication that eliminates symptoms of diarrhea and restores
Term Outcome: anal skin integrity by day of discharge

Nursing Actions: Decisions

Expected Short Term
Monitor/DirectCare/ Scientific Rationale Actual Outcomes (based on actual
Outcomes
Teaching (Label) outcomes)
"Doctors often suspect C.
difficile in anyone with diarrhea
Patient stool
Diarrhea Obtain stool specimens as who has taken antibiotics during
specimen delivered
Management: ordered to either rule out or the past two months or when • No more samples
to lab on 11/16 -
Management and diagnose an infectious diarrhea develops a few days needed at this time
check for results
alleviation of diarrhea process (C. difficile) (D) after hospitalization”("C. difficile:
11/17
Tests and diagnosis -
MayoClinic.com," 2010).

“Moisture from incontinence

promotes skin maceration
Maintain perirectal skin Patient’s skin has
(tissue softened by prolonged
integrity q1hr. Cleanse with stabilized but still • Continue to assess,
wetting or soaking) and makes
a perineal skin cleanser. irritated - tissue has monitor, and maintain
the epidermis more easily
Apply protective ointment not deteriorated the perirectal area
eroded and susceptible to
prn (D) further
injury” (Kozier, Erb, Berman &
Snyder, 2008, p. 905).

“Complications of C. difficile
infections include: Dehydration.
Assess hydration status for Patient has good • Continue to monitor
Severe diarrhea can lead to a
signs of dehydration and skin turgor at clavicle for dehydration even
significant loss of fluids and
electrolyte imbalance (M) and is not exhibiting though the risks seem
electrolytes”("C. difficile: S/S of Dehydration. lower.
Complications -
MayoClinic.com," 2010).

1
Student Name: Patient Initials & Room # Dates of Care:
Nursing Actions: Decisions
Expected Short Term
Monitor/DirectCare/ Scientific Rationale Actual Outcomes (based on actual
Outcomes
Teaching (Label) outcomes)

"The usual method to detect C.

difficile toxin A and B is by a • Progress may now be
rapid enzyme immunoassay. Patient’s C- diff test made towards a
Inquire about results of C-
Results are available after 1 to 4 results come back pharmacological
diff test run yesterday (D)
hours, depending on the test negative. intervention for the
“("Clostridium difficile toxin: The Patient
Test," 2010).

"A client advocate acts to

protect the client. In this role
the nurse may represent the
client 's needs and wishes to
Instruct client to consult
other health professionals.
with primary care
such as relaying the client's
practitioner regarding
wishes for information to the
receiving medication to aid
physician . They also assist
in solving the diarrhea
clients in exercising their
problem (T)
rights and help them speak
up for themselves"(Kozier,
Erb, Berman & Snyder, 2008, p.
14).
Client requests
• Patient will continue
medication to arrest
to take meds until he
diarrhea in consult
experiences
with Doctor - who
therapeutic effects that
finally writes a
eliminates symptoms of
prescription
diarrhea; tissues will
considering negative
get a chance to heal.
C-diff test result