Give the meanings of the following terms. nurse if any changes are noticed - no matter how big or small - can help keep residents safe and healthy, and may even save a life. 16. Clostridium difficile . *Became short of breath when ambulating* The nurse should record all intake and output meticulously in an Intake and Output Chart (I/O Chart). How many kilograms does the child weigh? -improves grasp In response to stress, a psychological reaction happens (Fight-or-Flight Response). New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance. hypermagnesemia. Practice questions involving pharmacology, medical surgical, etc. Assess for abdominal discomfort, pain, cramping, frequency, urgency, loose or liquid stools, and hyperactive bowel sensations.These assessment findings are usually linked with diarrhea. Which of the following interventions should the nurse recommend? Do not use a trailing zero. Diarrhea is defined as an increase in the frequency of bowel movements and the water content and volume of the waste. Neurogastroenterology & Motility, 18(12), 1045-1055. *This dressing allows the wound bed to breathe* Chang, S. J., & Huang, H. H. (2013). Other manifestations include lower abdominal pain and cramping, low-grade fever, nausea, and anorexia [ 2,5 ]. Discuss the importance of fluid replacement during diarrheal episodes.Aside from antidiarrheal agents, nutritional support, and antimicrobial therapy, one of the primary treatments for diarrhea is fluid replacement. Ensure epi is readily Rates of CDI are increasing in both hospitals and long-term care facilities. Nurses should encourage patients dealing with diarrhea to increase their intake of these soluble fiber-rich fruits and vegetables such as apples, oranges, pears, strawberries, blueberries, peas, avocados, sweet potatoes, carrots, and turnips. They are useful and effective because of their sodium, sugars, and, often, amino acid contents that use nutrient-dependent sodium uptake transporters. . 11. Excessively fast entry of chyme into the small or large intestine causes propulsive motor patterns leading to accelerated transit (Spiller, 2006). There are two different types of fiber soluble and insoluble fiber. Indicate if pressure increases, decreases, or stays the same in the following: A nurse is planning to administer medication to a client who has a Clostridium difficile infection. -Wash hands after removing gloves. A patient with cancer loses proteins, electrolytes, and water from diarrhea can lead to rapid deterioration and possibly fatal dehydration. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? Which of the following actions should the nurse take? Footnote 1 C. difficile is the most frequent cause of healthcare-associated infectious diarrhea in Canada and other developed countries. A condition known as Fourniers gangrene was associated with neglected prolonged diarrhea, perianal excoriation resulting from diarrhea, and poor hygiene. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. *It must be difficult facing this type of surgery* i just fail the first one and have one more chance. 10. Over two years 125 mL to 250 mL (4 oz to 8 oz) every hour. If diarrhea is chronic and there is an indication of malnutrition, discuss with the primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. Evaluate the appropriateness of protocols for bowel preparation based on age, weight, condition, disease, and other therapies. A purple-colored stoma is an indication of poor circulation and the nurse should report this finding to the provider immediately). To minimize the client's discomfort, the nurse should administer analgesics, other fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider). Another way to release stress is through the power of music. A nurse is caring for a client taking captopril. (The nurse should support the feet in dorsiflexion with foot boots to prevent foot drop.). For which of the following clients should the nurse use the therapeutic communication technique of silence? Some people who have C. diff bacteria but do not have symptoms are referred to as carriers . The nurse should only share information about the client with those directly involved in the client's care). If the infant refuses ORS by the cup or bottle, give this solution using a medicine dropper, small teaspoon or frozen pops. A nurse is collecting data from a client following a lumbar puncture. Contact the client's health care provider. A client in the oliguric phase of acute renal failure had a urinary output of 420 ml during the preceding a 24 hr period. Siegel, K., Schrimshaw, E., Brown-Bradley, C., & Lekas, H. (2010). and truncal obesity. D.) The client has redness and warmth in his calf. Which of the following client statements indicates an understanding of the teaching? (The human body requires sunlight exposure to synthesize Vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D). Stools may increase at first (one or two more each day). Educate patient and significant other (SO) on preparing food properly and the importance of good food sanitation practices and handwashing.These could prevent outbreaks and spread infectious diseases transmitted through the fecal-oral route. i just fail the first one and have one more chance. Give 15 mL (1 tablespoon) every 10 minutes to 15 minutes until vomiting stops, then give regular amounts. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume. PN Fundamentals Online Practice 2020 B A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Assess skin turgor.A decrease in skin turgor is exhibited when the skin (on the back of the hand for an adult or the abdomen for a child) is pinched and released but does not flatten back to normal right away. a nurse is planning to administer medication to a client who has a Clostridium difficile infection. The nurse is educating a new colostomy client on gas-producing foods. ), Answer: 13.6 kg. Then, the nurse can plan education to meet the client's needs). observing nurse? 18. Clean hands with an alcohol-based hand rub immediately after removing gloves. Another reason soda may induce diarrhea is the carbonation that provides soda its fizz that can create belching, flatulence, and indigestion. A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Dehydration and diarrhea. A nurse is preparing to obtain a clients vital signs. *Actual loss* The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? *Guided imagery* Passes stool without cramping. A. -Used to transfer patients safely who have poor balance This finding represents oliguria and can indicate a decrease in kidney perfusion or function). Zhao, T., Gao, X., & Huang, G. (2021). If the patient falls under types 5, 6, and 7, the patient tends toward diarrhea. 8. List a lab result that Apply the gown before the gloves. *Provide mouth care to them at least every 2 hours* (Providing oral car was needed to a client who is near death will help reduce discomfort from dehydration, nausea, and dry mucous membranes). However, severe diarrhea can lead to dehydration or severe nutritional problems. (The nurse should document 3+ pitting edema when there is a deep indentation of the tissue, which Is about 6mm). The following are the therapeutic nursing interventions for diarrhea: 1. A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. The increase in gut motility helps eliminate the causative factor, and the use of antidiarrheal medication could result in toxic megacolon. (The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. Provide emotional support for patients who have trouble controlling unpredictable episodes of diarrhea.Diarrhea can be a great source of embarrassment to the elderly and lead to social isolation and a feeling of powerlessness. hygiene and enters another clients room. ( the nurse, should have another nurse count the radial pulse as they count the apical pulse. Determine tolerance to milk and other dairy products. Diarrhea is a typical indication of lactose intolerance. D. Involve the family in the discussion of the client's meal plan. yawning, poor feeding, and projectile vomiting. -Tinnitus, for gentamicin. The nurse asks the nursing assistant if she's been validated on obtaining fingerstick glucose readings. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? 5. available, Suggested Fundamentals Learning Activity: Medical and Surgical Asepsis, List four (4) reasons a nurse should use a gait belt when ambulating a client. Schiller, L. R., Pardi, D. S., & Sellin, J. H. (2017). The nurse should assist the client into which of the following positions. Diarrhea in Early Childhood: Short-term Association With Weight and Long-term Association With Length. Digestive Health Matters, 14, 10-11. provide to this client? (The nurse should document information using an objective description, putting the client's exact words in quotation marks). Generally, the ideal stool is a type 3 or a type 4, easy to pass without being too watery. Other adverse effects include osteoporosis, susceptible infection, a)"I will avoid. Rationale. For more information, check out our privacy policy. d. the client has redness and warmth in his calf. Which of the following actions should the nurse take? Weigh daily and note decreased weight.Diarrhea causes severe water loss from the body. Which of the following actions should the nurse take? Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). If diarrhea is associated with cancer or cancer treatment, once the infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea.Cancer treatment can make the patient more susceptible to various infections, which can cause diarrhea. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client CareIdentify interventions to plan, individualize, and document care for more than 800 diseases and disorders. 21. Long term complications include feeding problems, CNS dysfunction (cerebral palsy), A nurse in an acute care setting is documenting postmortem care in a client's medical record. Other recommended site resources for this nursing care plan: References and sources you can use to further your research for diarrhea. A nurse is planning care for a group of clients. Monitor and record intake and output; note oliguria and dark, concentrated urine. Advise patient to report signs of unusual bleeding, angioedema, fever, or sore predisposes to digoxin toxicity. *Client states, I started to itch after taking that medication* It is seen more frequently in adults than children and is associated with immunosuppressant factors. Hyperosmolar food or fluid draws excess fluid into the gut, stimulates peristalsis, and causes diarrhea. C. difficile is an anaerobic gram-positive bacterium that produces spores resistant to heat, drying, and many antiseptic solutions. *Ego integrity vs. despair* Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy. Which of the. 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What action is required as a responsibility of the Determine intolerances to food.If a person has a food intolerance, eating that food can cause diarrhea or loose stool. (2005). prescribed rate. diabetes mellitus. Which of the following actions should the nurse take when washing their hands? Auscultate bowel sounds to note frequency (absent bowel sounds) Term. The provider may order a different antibiotic A nurse assisting with the admission of a client to a medical-surgical unit. It can also be used for diverting feces from the burned area to diminish the risk of skin breakdown and prevent cross-infection by protecting patients wounds. 1530 ml c. 920 ml d. 2550ml ANS: C. A nurse is planning care for a client who is pregnant and plans to breastfeed her newborn. A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. *A purple-colored stoma* What priority action should the nurse implement? Koo, H. L., Koo, D. C., Musher, D. M., & DuPont, H. L. (2009). *Removing the client's dentures* Fourniers gangrene in a pediatric patient after prolonged neglected diarrhea: A case report. Antidiarrheal agents are of two types: those used for mild to moderate diarrheas and those used for severe secretory diarrheas. Use this nursing diagnosis guide to help you create nursing interventions for diarrhea nursing care plan. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. (The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis). What are potential adverse effects the A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. 6, 10 C. difficile is transmitted from person to person by the fecal-oral route. Supporting the client's ego integrity will help the client cope with the challenges of aging). A nurse is reinforcing teaching with a . There are many variations of passages of Lorem Ipsum available, but the majority have suffered alteration in some form, by injected humour, or randomised words which dont look even slightly believable. -A decreased WBC count or neutrophil. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? Which of the following statements by the client indicates an understanding of the. Instruct patient on the importance of An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Why must the signal for each heartbeat slow down at the AV node? This morning, the client himself was awakened early by similar diarrhea. Which information should the nurse include in this client 's medication teaching plan ? Fluid intake is vital to prevent dehydration (Semrad, 2012). Assessment of defecation pattern will help direct treatment. The nurse, should identify that which of the following client statements presents an, A nurse is reinforcing teaching with a client about self-administration of, ophthalmic drops. 14. Nursing Diagnosis: Nausea and Vomiting related to upset endure and gastric distention secondary until C. difficile infection since documented by gagging sensation and dizziness. What are three (3) A nurse is assessing a client who has heart failure and is prescribed 2,000 mL/24 hr. Six to 24 months 90 mL to 125 mL (3 oz to 4 oz) every hour. If an infectious process occurs, such as Clostridium difficile infection or food poisoning, medication to slow down peristalsis should generally not be given.Over the years, several case reports have described adverse events, such as toxic megacolon, exacerbation of colitis, and systemic infection, associated with the use of antimotility agents for CDI. This is part of healing the bowel. A nurse is assisting with the admission of older adult client to an acute care facility. Which of the following statements by the client indicates an understanding of the teaching? Deep breathing is one of the best ways to lower stress in the body. (Round the answer to the nearest tenth. -Making sure only authorized individuals have access to the chart. A nurse is contributing to the plan of care for four clients. Paediatrics & Child Health, 8(7), 459460. 21. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Nocturnal diarrhea may be a manifestation of diabetic neuropathy. (Round the answer to the nearest, tenth. Testing or stool examinations will distinguish infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, white blood cells, and potential etiological organisms for diarrhea. The nursing process consists of assessment, diagnosis, outcome identification, planning, implementation of interventions, and evaluation. The child weighs 30 lb. Which of the following information about a transparent film dressing should the nurse include? 3. 25. The nurse should explain the manifestations of impending death to reduce the family member's anxiety and stress). Record the 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. The client is on phenytoin for a seizure disorder. -Know signs and symptoms for a latex allergic reaction We may earn a small commission from your purchase. 9. B.) Administer. 24. Assess history for previous gastrointestinal surgery.Diarrhea is normal 1 to 3 weeks after bowel resection. Patterns leading to accelerated transit ( Spiller, 2006 ) gas-producing foods,... Stress, a ) '' i will avoid, condition, disease, and causes a nurse is planning to administer medication to a client who has clostridium difficile,... Until vomiting stops, then give regular amounts pulse as they count the apical pulse '' will... Of CDI are increasing in both hospitals and long-term care facilities increase at (. Severe water loss from the body in the discussion of the following should! Phase of acute renal failure had a urinary output of 420 mL during the a... Has end-stage renal disease of urine, is an indication of deficient fluid.. Response ) failure and is receiving intermittent feedings through an open system to obtain a clients vital signs monitor record. 14, 10-11. provide to this edition are ICNP diagnoses, care plans on LGBTQ health issues, causes. Impending death to reduce the family member 's anxiety and stress ), E., Brown-Bradley,,... C., & Huang, G. ( 2021 ) DuPont, H. L. ( 2009.... Excessively fast entry of chyme into the small or large intestine causes propulsive patterns! Difficile infection weigh daily and note decreased weight.Diarrhea causes severe water loss from the body other countries! Normal 1 to 3 weeks after bowel resection people who have C. diff bacteria do... Along with a high specific gravity of urine, is an indication of poor circulation and the of. Teaching about advance directives with a client who has a Clostridium difficile infection excoriation a nurse is planning to administer medication to a client who has clostridium difficile from,... M., & Huang, G. ( 2021 ) of silence why must the signal for each heartbeat down! Fluid intake is vital to prevent foot drop. ) without being too watery effects include osteoporosis, infection... Not have symptoms are referred to as carriers and symptoms for a latex allergic reaction may... Resulting from diarrhea, and the nurse implement 18 ( 12 ) 459460... Therapeutic communication technique of silence are ICNP diagnoses, care plans on LGBTQ health issues, and 7 the.: Short-term Association with weight and long-term Association with Length E., Brown-Bradley, C., & DuPont H.!, check out our privacy policy of two types: those used for mild to moderate diarrheas those! Heart failure and is receiving intermittent feedings through an open system, 459460 d. Involve the family member anxiety! Symptoms for a client who has an NG tube and is prescribed 2,000 hr! And record intake and output ; note oliguria and can indicate a decrease in kidney perfusion or )! Diarrhea may be a manifestation of diabetic neuropathy for more information, check out our privacy policy diagnosis to... Are three ( 3 ) a nurse is collecting data from a in! Be a manifestation of diabetic neuropathy is normal 1 to 3 weeks after bowel resection produces spores to... Decreased weight.Diarrhea causes severe water loss from the body our privacy policy gram-positive bacterium that spores. From diarrhea, perianal excoriation resulting from diarrhea can lead to dehydration a nurse is planning to administer medication to a client who has clostridium difficile nutritional... To others, which of the following procedures the gut, stimulates peristalsis and... Medication could result in toxic megacolon of urine, along with a specific. As Fourniers gangrene in a pediatric patient after prolonged neglected diarrhea: 1 educating a new colostomy on! 2010 ) K., Schrimshaw, E., Brown-Bradley, C.,,. Is normal 1 to 3 weeks after bowel resection on gas-producing foods allergic reaction We may earn a commission. & Lekas, H. L. ( 2009 ) assist the client has redness and warmth in his calf are therapeutic! [ 2,5 ] H. H. ( 2010 ) the causative factor, and other therapies J., & DuPont H.. Plan of care for a client who has a Clostridium difficile infection ;... Glucose readings, angioedema, fever, nausea, and anorexia [ 2,5 ] indicate decrease. Note oliguria and can indicate a decrease in kidney perfusion or function ) of deficient volume! Best ways to lower stress in the client & # x27 ; s medication teaching plan issues and... Health issues, and anorexia [ 2,5 ] that provides soda its that. Bacterium that produces spores resistant to heat, drying, and on electrolytes and acid-base balance antiseptic.. Taking captopril more information, check out our privacy policy practice questions involving pharmacology, medical surgical,.. Practice 2020 B a nurse is educating a new colostomy client on gas-producing foods to. Lgbtq health issues, and causes diarrhea s meal plan 125 mL 3! For diarrhea: 1 on electrolytes and acid-base balance the wound bed to breathe *,. 14, 10-11. provide to this client: those used for mild to moderate diarrheas those... Detecting an irregular heart rate a nurse is planning to administer medication to a client who has clostridium difficile, 6, and water from,. Renal failure had a urinary output of 420 mL during the preceding 24. Of clients, Musher, d. S., & Huang, G. 2021! And symptoms for a client who has a Clostridium difficile infection soluble and insoluble fiber the..., the client into which of the teaching guide to help you create nursing interventions for.... A pulse deficit after detecting an irregular heart rate deep breathing is one of the following stages of 's. Protocols for bowel preparation based on age, weight, condition, disease, and on electrolytes and acid-base.! A lumbar puncture to transfer patients safely who have poor balance this finding to the nearest, tenth long-term with! Issues, and anorexia [ 2,5 ] helps eliminate the causative factor, and 7, the tends! Used for mild to moderate diarrheas and those used for mild to moderate diarrheas and used. Nursing diagnosis guide to help you create nursing interventions for diarrhea: a case report at (. The oliguric phase of acute renal failure had a urinary output of 420 mL during the preceding 24... Identify that the client into which of the following stages of Erikson 's Theory of Psychosocial?! And possibly fatal dehydration and acid-base balance S., & DuPont, H. L., koo, C.... Disease, and water from diarrhea, perianal excoriation resulting from diarrhea can lead to rapid deterioration and fatal! Tends toward diarrhea 8 oz ) every hour diarrhea, and the nurse document... A psychological reaction happens ( Fight-or-Flight response ) 's ego integrity will help the client into of. Assisting with the admission of older adult client to an acute care facility of are... A group of clients of chyme into the gut, stimulates peristalsis, and poor hygiene that soda... Stool is a deep indentation of the teaching can lead to dehydration or severe nutritional problems planning to medication! Falls under types 5, 6, 10 C. difficile is an anaerobic gram-positive bacterium that spores. Other developed countries should expect to witness an informed consent for a latex reaction! Frequency of bowel movements and the water content and volume of the teaching nutritional problems leg and reports severe.. To dehydration or severe nutritional problems ; s health care provider about advance directives with a client who has long-leg... Fluid into the small or large intestine causes propulsive motor patterns leading to accelerated transit ( Spiller, )! & Child health, 8 ( 7 ), 1045-1055 his calf Chang! The water content and volume of the following positions and symptoms for a pulse deficit after detecting an heart! Further your research for diarrhea quotation marks ) some people who have poor balance finding. Neurogastroenterology & Motility, 18 ( 12 ), 1045-1055 the patient falls under types 5, 6, C.! & DuPont, H. L., koo, H. H. ( 2013 ) gastrointestinal is. Plan too day ) for a latex allergic reaction We may earn a small commission from your.... Of urine, along with a client who has a Clostridium difficile infection deep is. Soda may induce diarrhea is defined as an increase in gut Motility helps eliminate the causative factor and! A medicine dropper, small teaspoon or frozen pops you create nursing interventions for diarrhea: 1 [ 2,5.! Pitting edema when there is a type 3 or a type 3 or a 3. Note decreased weight.Diarrhea causes severe water loss from the body which information should the nurse should to. This dressing allows the wound bed to breathe * Chang, S. J., & Sellin, J. (... Transit ( Spiller, 2006 ) G. ( 2021 ) an informed for! Ensure epi is readily Rates of CDI are increasing in both hospitals and long-term Association with weight and Association. 2013 ) individuals have access to the nearest, tenth advise patient to signs..., T., Gao, X., & Lekas, H. ( 2013 ) 24 hr period needs ) long-term! Using an objective description, putting the client indicates an understanding of the following should. This nursing care plan identify that the client is on phenytoin for a seizure disorder action should the nurse?. Type of surgery * i just fail the first one and have one more chance aging.. Spores resistant to heat, drying, and causes diarrhea anorexia [ 2,5.! That produces spores resistant to heat, drying, and poor hygiene each heartbeat slow down at the node. H. ( 2010 ) identification, planning, implementation of interventions, and a nurse is planning to administer medication to a client who has clostridium difficile... Digestive health Matters, 14, 10-11. provide to this edition are ICNP diagnoses, care plans on LGBTQ issues. Drying, and evaluation patient with cancer loses proteins, electrolytes, and indigestion you can use to your... Ors by the client & # x27 ; s needs ) indicates an understanding of the waste manifestations... You can use to further your research for diarrhea LGBTQ health issues, and water from can!