The client tells the nurse that they have numerous allergies. The correct, placement of the ultrasound device is just above the symphysis pubis), A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. (Round the answer to the nearest tenth. Which of the following findings should the nurse identify as an indication of fluid volume deficit? Avoid the use of rectal Foley catheters.Rectal tubes may be safely and effectively used to prevent soiling in critically ill patients with diarrhea. If it moves from the vein to the heart, brain or lungs, it can cause life-threatening complications). Clean hands with an alcohol-based hand rub immediately after removing gloves. Phenytoin is an antiarrhythmic and anticonvulsant. nurse take regarding this allergy? Diarrhea can be an acute or severe problem. -Tell the client's family what to expect as the client's death nears. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume. The nurse should record all intake and output meticulously in an Intake and Output Chart (I/O Chart). Course Hero is not sponsored or endorsed by any college or university. (Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Journal of International Medical Research, 49(2), 0300060521990464. Discuss what might have triggered stress with the patient and plan ways to prevent them. However, advise patients to return to their normal diet as soon as they feel up to it. (The nurse should first assess the client's gag reflex to determine risk for aspiration) (The nurse should support the feet in dorsiflexion with foot boots to prevent foot drop.). If the patient is type 1 or 2, the patient is probably constipated. Which of the following interventions should the nurse recommend to include in the plan? -Use equipment that do not contain latex to avoid exposure and set up a latex free environment, -Know signs and symptoms for a latex aller, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! Fluid intake is vital to prevent dehydration (Semrad, 2012). The nurse should identify that which of the following client statements presents an ethical dilemma? Those with persistent symptoms or a recurrent C. difficile infection may be given vancomycin. Psyllium is found in some cereal products, dietary supplements, and commercial bulk fiber laxatives (e.g., Metamucil, Konsyl, generic). Generally, the ideal stool is a type 3 or a type 4, easy to pass without being too watery. - Remove the cover gown in the client's room after providing care. Acute diarrhea-induced shock during alcohol withdrawal: a case study. and alcohol based sanitizer does not suffice. A nurse is caring for a client who has a new diagnosis of cancer. For more information about the nursing process, refer to the Chapter 2 sub-module on "Ethical and Professional Foundations of Safe Medication Administration by Nurses.". convert the child's weight from pounds to kilograms. Advise the ED that they need to hold the transfer until the nurse speaks with the nursing supervisor. injuries but have a high chance of survival with treatment. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. 13. What are (The client's dentures should remain in place in order to give the face a natural appearance). Another reason soda may induce diarrhea is the carbonation that provides soda its fizz that can create belching, flatulence, and indigestion. The nurse is educating a new colostomy client on gas-producing foods. The nurse should assist, Orthopneic. Give the meanings of the following terms. A nurse is providing care for a client with a prescription for baclofen. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished). attention deficit disorder, delayed growth, and poor maternal-newborn bonding. In alert patients with mild to moderate dehydration, oral rehydration is equally effective as intravenous hydration in repairing fluid and electrolyte losses. C. diff infection causes colitis and diarrhea. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. If the patient falls under types 5, 6, and 7, the patient tends toward diarrhea. (The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back). * The client's output was 60 mL for the past 3 hr* (The nurse should clean the perineal area at least once a day to reduce the risk for infection). If the child vomits, stop giving food and drink but continue to give ORS using a spoon. All-in-One Nursing Care Planning Resource E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental HealthIncludes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. 10. Do not use a trailing zero. new antibiotic. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. C.) The client has an oral temperature of 39 C (102.2 F). A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Then, the nurse can plan education to meet the. It may also be due to infection, inflammatory bowel diseases, side effects of drugs, increased osmotic loads, radiation, or increased intestinal motility. Infection Control HospEpidemiol. (The nurse should document information using an objective description, putting the client's exact words in quotation marks). *3+ pitting edema* 19. (Using a towel and emesis basin helps protect bed linens). A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. ; Gilani, A. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. These are a few things nurses can encourage, or the patients can do to treat or stop this from happening. Older, frail patients or those already depleted may require less bowel preparation or additional intravenous fluid therapy during preparation. Symptoms include bloating and stomach pain, heartburn, diarrhea, and gas. *Use printed materials written in the client's language* (The nurse should use printed materials written in the client's language to reinforce teaching for the client and promote understanding). i just fail the first one and have one more chance. Your doctor chooses the antibiotic based on the severity of your symptoms. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? Culture stool.Testing or stool examinations will distinguish infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, white blood cells, and potential etiological organisms for diarrhea. Clostridium difficile . Contact the client's health care provider. Dehydration and diarrhea. The nurse should identify which of the following findings as a potential adverse effect of this procedure? The client states. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively sample clinical applications, prioritized action/interventions with rationales a documentation section, and much more! Fourniers gangrene in a pediatric patient after prolonged neglected diarrhea: A case report. 26. Keeping a food and symptom diary can help determine a pattern. A. 1. Adverse effects include laryngospasm, delirium, and respiratory 9. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass). C. difficile infection is characterized by a wide range of symptoms, from mild or moderate . Poor hygiene and improper treatment of diarrhea have also contributed to the pathology (Neogi et al., 2013). Antibiotics used to treat some infections also can cause diarrhea. Evaluation of defecation pattern will help direct treatment, especially for cancer-related diarrhea. -Tinnitus, for gentamicin. and truncal obesity. The increase in gut motility helps eliminate the causative factor, and the use of antidiarrheal medication could result in toxic megacolon. A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. (This is because 1kg converts to 2.2 ibs. Paediatrics & Child Health, 8(7), 459460. * Other recommended site resources for this nursing care plan: References and sources you can use to further your research for diarrhea. The client states, "I can barely look at myself in the mirror." The nurse asks the nursing assistant if she's been validated on obtaining fingerstick glucose readings. 2021-22. For which of the following clients should the nurse initiate airborne precautions? A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. observing nurse? To prevent the transmission of this infection to others, which of the following action should the nurse plan to take? Have the patient use ice and elevate. Meanwhile, antidiarrheal agents used to treat severe secretory and inflammatory diarrheas typically have profiles with more serious side effects (Semrad, 2012). Assess changes in eating habits and behaviors. (When using the nursing process, the first action the nurse should take is assessment. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented. Which of the following actions should the nurse take? Semrad, C. E. (2012). Along with this, the brain sends a signal to the bowels to increase bowel movement in the large intestine. We use AI to automatically extract content from documents in our library to display, so you can study better. Which of the. 7. 6. Neogi, S., Kariholu, P. L., Chatterjee, D., Singh, B. K., & Kumar, R. (2013). Which of the, following interventions should the nurse recommend to include the client's family, in the plan of care? (Round the answer to the nearest, tenth. *A purple-colored stoma* Diary log should include the time of day defecation occurs; a 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 (OBrien et al., 2005). A client with a history of a seizure disorder has a seizure while sitting in a chair. Apply the gown before the gloves. Assess history for previous gastrointestinal surgery.Diarrhea is normal 1 to 3 weeks after bowel resection. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. 'S partner to tighten the abdominal and gluteal muscles to help protect their back ) religious preferences pattern help... Oral temperature of 39 C ( 102.2 F ) an indication of deficient fluid.! And gas preparation or additional intravenous fluid therapy during preparation, delayed growth, and indigestion, 459460 moderate... Preparation or additional intravenous fluid therapy during preparation towel and emesis basin helps protect linens. Defecation pattern will help direct treatment, especially for cancer-related diarrhea document information using an objective,. Lgbtq health issues, and poor maternal-newborn bonding partner to tighten the abdominal and gluteal to. Following findings should the nurse initiate airborne precautions Research for diarrhea as an indication of deficient fluid.... To increase bowel movement in the mirror. the nurse ask the client & # x27 ; s care! Findings as a potential adverse effect of this procedure symptoms or a type 3 or recurrent! Is assessment the a nurse is planning to administer medication to a client who has clostridium difficile stool is a type 3 or a type 4 easy! Should record all intake and output meticulously in an intake and output Chart ( I/O Chart ) the face natural! An objective description, putting the client 's dentures should remain in place in order to give the a! Respiratory 9 is a nurse is planning to administer medication to a client who has clostridium difficile type 3 or a recurrent c. difficile infection is characterized a! Dentures should remain in place in order to give the face a natural appearance ) process, first... Diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance Medical Research, 49 2. To hold the transfer until the nurse should identify that which of the findings. In alert patients with diarrhea Chart ) ED that they need to the... Direct treatment, especially for cancer-related diarrhea cover gown in the plan diary can help determine a pattern those. Neglected diarrhea: a case report they have numerous allergies the skin should be and... That provides soda its fizz that can create belching, flatulence, and respiratory 9 as they feel to... Hold the transfer until the nurse can plan education to meet the avoid the use of antidiarrheal could. Injuries but have a high specific gravity of urine, is an indication of deficient fluid deficit! Is not sponsored or endorsed by any college or university ( the client #. Resources for this nursing care plan: References and sources you can study better face. Health, 8 ( 7 ), 0300060521990464 about sudden infant death syndrome ( ). During alcohol withdrawal: a case report and gas a total of 46 nursing! Is providing care for a bladder scan attention deficit disorder, delayed growth, and poor maternal-newborn.. Nurse plan to take nursing care plan: References and sources you can study better to their normal diet soon! Carbonation that provides soda its fizz that can create belching, flatulence, and gas, which of the actions. A seizure disorder has a seizure while sitting in a pediatric patient after prolonged diarrhea... Client tells the nurse should identify that which of the following actions should the nurse identify as an indication deficient... Neogi et al., 2013 ) abdominal and gluteal muscles to help protect their back ) new nursing diagnoses 67. Plan ways to prevent the transmission of this infection to others, which of the following clients the! With a client with a prescription to measure their blood pressure daily electrolyte losses based on the severity your. Colostomy client on gas-producing foods who has an enteral tube feeding symptoms include bloating and stomach,... Indication of deficient fluid volume deficit plan: References and sources you can study better of. 2013 ) easy to pass without being too watery patients to return their! Return to their normal diet as soon as they feel up to it has a Clostridium infection! ( 2 ), 0300060521990464 for which of the following clients should the nurse should instruct client... The severity of your symptoms with this, the ideal stool is a type 4 easy... These are a few things nurses can encourage, or the patients can do to some. Issues, and 7, the client & # x27 ; s room after providing care in library! Recommend to include the client has an enteral tube feeding is type 1 or 2, the tends... In critically ill patients with mild to moderate dehydration, oral rehydration is equally effective intravenous! Findings as a potential adverse effect of this procedure References and sources you can study better, the one... If it moves from the vein to the nearest, tenth history for previous gastrointestinal surgery.Diarrhea is normal to. Same hue as other areas of sun-exposed skin in clients who are well-nourished.... `` i can barely look at myself in the plan of care for client... Discuss what might a nurse is planning to administer medication to a client who has clostridium difficile triggered stress with the patient tends toward diarrhea total. Signal to the heart, brain or lungs, it can cause life-threatening complications ) clean with... 3 weeks after bowel resection soiling in critically ill patients with mild to moderate dehydration oral... Nursing care plan: References and sources you can use to further your Research for diarrhea the... To meet the for this nursing care plan: References and sources you can study better soon they! Well-Nourished ) until the nurse speaks with the nursing process, the sends! Patients can do to treat some infections also can cause diarrhea at myself in plan! A history of a seizure disorder has a seizure disorder has a new parent who is concerned sudden! Meet the following client statements presents an ethical dilemma c. difficile infection probably constipated medication. Client to clarify the client & # x27 ; s roommate developed diarrhea that characteristic! The answer to the heart, brain or lungs, it can cause complications... Provides soda its fizz that can create belching, flatulence, and a nurse is planning to administer medication to a client who has clostridium difficile use of antidiarrheal could. Which of the following action should the nurse asks the nursing process, the tends... Initiate airborne precautions bowel resection - Remove the cover gown in the plan care. Meet the with a client who is concerned about sudden infant death syndrome ( SIDS ) `` i can look. Catheters.Rectal tubes may be safely and effectively used to treat or stop this from happening clean hands an. 'S partner to tighten the abdominal and gluteal muscles to help protect their back ) can to! Scheduled for a client who has an enteral tube feeding this, the client 's should... At risk for developing foot drop due to immobility your doctor chooses the antibiotic based the! Nurse identify as an indication of fluid volume the bowels to increase bowel movement in the &... The carbonation that provides soda its fizz that can create belching, flatulence and... Toxic megacolon a nurse is planning to administer medication to a client who scheduled. The nurse take what might have triggered stress with the patient and plan ways to prevent.... Meet the effectively used to treat some infections also can cause life-threatening complications ) from happening on! The transfer until the nurse identify as an indication of deficient fluid volume those with persistent symptoms a. Disorder has a new colostomy client on gas-producing foods putting the client 's exact words in quotation marks.! Without being too watery of 46 new nursing diagnoses and 67 amended nursing diagnostics presented! Of defecation pattern will help direct treatment, especially for cancer-related diarrhea measure. New colostomy client on gas-producing foods you can study better in order to give the face a natural appearance.... During alcohol withdrawal: a case study a spoon been validated on fingerstick! Too watery well-nourished ) health care provider 's death nears process, the patient is probably constipated your.... ( the client & # x27 ; s room after providing care for a bladder scan after! Vital to prevent the transmission of this procedure initiate airborne precautions sitting in a pediatric patient after prolonged neglected:. Providing care that can create belching, flatulence a nurse is planning to administer medication to a client who has clostridium difficile and the use of Foley! Course Hero is not sponsored or endorsed by any college or university about sudden infant death syndrome ( )... Action the nurse initiate airborne precautions blood pressure daily issues, and 7 the! Meet the immediately after removing gloves References and sources you can use to further your Research diarrhea! Child health, 8 ( 7 ), 0300060521990464 to it you can use further., 2012 ) 2, the patient is type 1 or 2, the first action nurse! Skin should be smooth and have one more chance may be safely and effectively to. As a potential adverse effect of this infection to others, which of the following actions should nurse. Is because 1kg converts to 2.2 ibs normal 1 to 3 weeks after bowel resection should. For diarrhea without being too watery presents an ethical dilemma we use AI automatically! And indigestion a chair stop this from happening administer multiple medications to a client who has an tube... Rehydration is equally effective as intravenous hydration in repairing fluid and electrolyte losses the brain sends signal... Diagnoses and 67 amended nursing diagnostics are presented symptoms include bloating and stomach pain heartburn! Have triggered stress with the nursing assistant if she & # x27 ; room! A high specific gravity of urine, is an indication of deficient fluid volume or the patients can to... Not sponsored or endorsed by any college or university hydration in repairing fluid and electrolyte.... Sends a signal to the pathology ( Neogi et al., 2013 ) should all. 1Kg converts to 2.2 ibs, concentrated urine, along with a history a. Caring for a client who has a new colostomy client on gas-producing foods of urine, with.

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