Blessed Angelique Marie Bucio Mira BSN II N21

NURSING CARE PLAN CONFERENCE

Assessment Diagnosis Planning Intervention Rationale Evaluation
Short term: Independent: Short term:
1. Review medical, surgical, -To identify conditions commonly
Subjective Cues: “Wala Constipation related to Within 8 hours of nursing and social history. associated with constipation. After 8 hours of nursing
pako kalibang sugod pag abdominal muscle interventions the patient 2. Review daily dietary -Inadequate dietary fiber and highly interventions the patient
regimen, noting if diet is processed foods can contribute to poor
opera” weakness secondary to Post will be able to identify deficient in fiber. intestinal function. was able to identify
Objective Cues: TAHBSO appropriate interventions to 3. Encourage patient to -Inadequate dietary fiber contribute to appropriate
increase fiber intake. poor intestinal function.
-4 days constipated regain normal pattern of 4. Promote adequate water - Sufficient fluid is needed to keep the interventions to regain
-Distended abdomen as bowel functioning. intake fecal mass soft normal pattern of bowel
5. Determine patient’s fluid -To note deficits
observed intake. functioning. Goal met.
-Post TAHBSO Long term: Within 3 days 6. Note energy and activity -Lack of physical activity or regular
levels and exercise pattern. exercise is often a factor in constipation.
-With abdominal binder of nursing interventions the 7. Identify life changes or -Individuals may fail to allow time for Long term: After 3 days
-Change in bowel pattern patient will be able to stressors good bowel habits and/or suffer of nursing interventions
gastrointestinal effects from stress.
-Decrease fluid intake as demonstrate behaviors and 8. Determine access to -The need for privacy is fundamental for the patient was able to
verbalized lifestyle changes to prevent bathroom, privacy and most clients. demonstrate behaviors
ability to perform self-care
-Limited movement as recurrence of problem. activities. and lifestyle changes to
seen 9. Investigate reports of pain -Hemorrhoids, rectal fissures or prolapse prevent recurrence of
with defecation skin breakdown or other abnormal
-Inaccessibility of comfort findings may be passage of stools or problem. Goal met.
rooms causing client to hold stool.
Dependent
-Less fiber intake as 10. Note the pharmacological -To determine the effectiveness of the
verbalized agent the client has used current regimen.
11. Evaluate the client’s -That could cause/exacerbate
medications or drug usage constipation
Collaborative
12. Establish bowel program to -When long term or permanent bowel
include predictable interval dysfunction is present.
timing for colostomy
irrigation or toileting
13. Refer to primary care To best treat acute situation
provider for medical
therapies