RLE 002

Cebu Normal University

College of Nursing Cebu City
Mission-Vision: Care Using Knowledge and Compassion Theory-based (Betty Neuman)

NURSING CARE PLAN

Assessment 3 points Goals Diagnosis 3 points Theoretical Basis 2 points 2 points Evaluation Interventions 1 point 4 points 15 points Bibliography

Name of Student:_Judaperl D. Cabanag ______ Clients Initials:_C.T.J_______________________________________ Age: _62 y/o_ Gender: Male Civil Status:Married Religion:R. Catholic Allergies: _no known allergies to food and drugs______________ Diet:_as tolerated _______________________________ Date of Admission:________________________________________ Diagnosis/Impression:_____________________________________

Clinical Instructor: _Mr. Julius C. Dao, RN _ Stressor Classification: (Please check) ____ Physiological (body structure and functions) ______ Psychological (mental processes and emotion) ______ Socio-cultural (relationships, expectations) ______ Spiritual (influence of spiritual beliefs) ______ Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS
Assessment Subjective: Duha ka semana na kong wa kalibang, as verbalized by patient. Objective: received lying on bed conscious and coherent belongs to the elderly population irritability and restlessness noted abdominal distention noted Diagnosis Constipation related to prolonged inactivity following abdominal surgery

NURSING GOALS
Mutual Planning
(Goal attainable within the shift)

NURSING OUTCOME
Interventions
(with Rationale & Source)

Actual Evaluation

After 8 hours of nursing interventions, patient will be able to: verbalize measure to promote defecation and prevent recurrence of constipation passes soft, formed stool

PRIMARY INTERVENTIONS Promotive:

I: Educate patient on the importance of bowel elimination and activities to promote such. R: Enhances compliance. S: Gulanick & Myers, 2007 I: Allow for time to relax while assuming a high fowlers position with knees flexed. R: This position best uses gravity and allows dor effective valsava maneuver. S: Gulanick & Myers, 2007

Preventive:
I: Encourage daily intake of 2000 to 3000ml/day R: Fluids soften stools for easy defecation S: Gulanick & Myers, 2007 I: Encourage to increase fiber in the diet such as fresh vegetables, raw fruits, whole grains.

 reported on frequent but nonproductive desire to defecate reluctance to ambulate for longer periods decreased desire of oral fluid intake observed

Theoretical basis: Constipation is a common yet complex problem; it is especially prevalent among older patients. It is defined as a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stools. Diet, exercise and daily routine are important factors in maintaining normal bowel pattern. Too little fluid, too little fiber, inactivity and disruption in daily routines can result to decrease in peristaltic movement thus, resulting to constipation. - Gulanick & Myers, 2007

R: Fiber absorbs water and adds bulk to the stool. S: Gulanick & Myers, 2007 I: Encourage physical activity and regular exercise as tolerated. R: Ambulation strengthens abdominal muscle for defecation and increase in peristalsis. S: Gulanick & Myers, 2007

SECONDARY INTERVENTIONS Curative

I: Administer enema, stool softeners or bulk fiber as prescribed. R: These pharmacologic interventions soften stools and encourages defecation. S: Gulanick & Myers, 2007 I: Consult dietitian as appropriate. R: This personnel can recommend the appropriate diet for the client. S: Gulanick & Myers, 2007

TERTIARY INTERVENTIONS Rehabilitative

I: Offer an alternating warmed and cold compress on abdomen. R: Facilitates peristaltic movement. S: Gulanick & Myers, 2007 I: Provide privacy and relaxation. R: Decrease stimuli can help patient focus and promote defecation.

Bibliography: _____________________________________________________________________________________________________________________________ ______________Gulanick, M & Myers, J. (2007). Nursing Care Plans. 6th ed. Elsevier
(Singapore). Pte. Ltd.________________________________________________________