16.23 Spotlight Activity
The following activity highlights how to apply the nursing process and the clinical judgment model to a pediatric client with a gastrointestinal illness.
Client Background
Jane, a six-year-old girl, is brought to the pediatric clinic by her mother due to complaints of diarrhea over the past two days. Jane is otherwise healthy and attends kindergarten regularly. Her mother reports that Jane has had loose, watery stools about five to six times a day, accompanied by mild abdominal discomfort and nausea. There is no history of fever, vomiting, recent travel, or changes in diet.
1. What priority assessment data should the nurse collect at this time? (Assessment/Recognizing Cues)
The nurse should first note Jane’s current symptoms: loose and watery stools, increased stool frequency, mild abdominal discomfort, and nausea.
Other nursing assessments that should be done at this time are the following:
- Obtain a complete set of vitals to assess for signs of dehydration
- Complete an abdominal assessment, including bowel sounds
- Examine for other indicators of hydration status: urine output, mucous membranes, and skin turgor
- Determine if Jane has had any sick contacts with similar symptoms
- Examine the appearance of stool for color, odor, and presence of blood or mucus
- Determine if Jane has recently been on antibiotics or consistently takes other medications that can lead to diarrhea
- Assess for chronic illnesses that could cause diarrhea
- Assess skin in the peri-area for skin breakdown
2. Based on the assessment data provided, which nursing diagnoses would be appropriate at this time? (Diagnosis/Analyzing Cues)
- Diarrhea r/t disease process
- Risk for fluid volume deficit r/t increased bowel movements
- Risk for impaired skin integrity r/t increased bowel movements
- Risk for electrolyte imbalance r/t increased bowel movements
3. Provide a sample of expected outcomes that would be appropriate for Jane. (Outcome Identification/Generate Solutions)
- Jane will exhibit formed stools that occur at her normal frequency within one week.
- Jane will exhibit a blood pressure, heart rate, and urine output within normal limits for her age, as well as moist mucous membranes.
- Jane will exhibit skin in the peri-area that is an appropriate color for race and free from skin breakdown during the course of her illness.
- Jane will exhibit electrolyte levels that are within normal limits during the course of her illness.
4. What nursing interventions would be appropriate for this client? (Planning & Implementation/Generate Solutions & Take Action)
Immediate nursing interventions that would be appropriate are as follows:
- Perform oral rehydration to prevent/treat dehydration. If nausea is severe, or vomiting occurs, intravenous rehydration may be required.
- Monitor intake and output and vital signs.
- Apply barrier cream to the peri-area if needed.
- Monitor stool frequency and consistency.
- When nausea resolves, encourage a bland diet. High-fiber and spicy foods should be avoided, as well as dairy products.
- Encourage the use of heat and relaxation to ease abdominal discomfort.
- Teach Jane and her caregivers about the need for hand hygiene to prevent the spread of illness.
Other nursing interventions may be appropriate based on Jane’s specific diagnosis and the course of her illness.
5. How would you evaluate if Jane’s outcomes were met? (Evaluation/Evaluate Outcomes)
Every time the nurse interacts with Jane, outcomes should be evaluated. Continued assessment of Jane’s vital signs, stool frequency, hydration status, and any available lab work will help the nurse determine if outcomes are met, partially met, or not met. If outcomes are partially met or not met, the nurse may need to continue monitoring Jane’s progress or the care plan may need revision.