In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
A. The client passes formed stools at regular intervals.
B. The client reports a decrease in stool frequency and liquidity.
C. The client exhibits firm skin turgor.
D. The client no longer experiences perianal burning.
Correct Answer: C. The client exhibits firm skin turgor.
A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. Evaluate dehydration by observing skin turgor over the sternum and inspecting for longitudinal furrows of the tongue.
Option A: The client also has a nursing diagnosis of diarrhea, with expected outcomes of passage of formed stools at regular intervals and a decrease in stool frequency and liquidity. Give antidiarrheal drugs as ordered. Record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output.
Option B: Have patient keep a diary that includes the following: time of day defecation occurs; 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.
Option D: The client is at risk for impaired skin integrity related to irritation from diarrhea; expected outcomes for this diagnosis include absence of erythema in perianal skin and mucous membranes and the absence of perianal tenderness or burning. Mild cleansing of the perianal skin after each bowel movement will prevent excoriation. Barrier creams can be used to protect the skin.
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