NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Constipation • Hirschsprung’s After 8 hours of • Determine stool • Assists in After 8 hours of
related to nursing color, identifying nursing
“Hindi madumi changes in disease interventions, interventions,
consistency, causative or
ang anak ko” (My digestive (congenital the patient will frequency, and contributing the patient was
baby is constipated) process. aganglionic demonstrate amount. factors and able to
as verbalized by megacolon) is changes in appropriate demonstrate
the mother. behavior as intervention. changes in
the congenital
absence of or
necessitated by • Auscultate bowel • Bowel sounds behavior as
Objective: causative and sounds. are generally necessitated by
arrested contributing increased in causative and
• Altered bowel development of factors. constipation. contributing
sounds. parasympatheti • Monitor intake • May identify factors.
c ganglion cells and output (I&O) dehydration,
• Reports of with specific excessive loss
in the intestinal
abdominal attention to food of fluids or aid
pain or wall, usually in
or fluid intake. in identifying
cramping. the distal colon. dietary
Symptoms are deficiencies.
• V/S taken as related to • Recommend • Decreases
follows: chronic avoiding gas gastric distress
intestinal forming foods. and abdominal
T: 36.5 distension.
P: 130 obstruction and
• Assess perianal • Prevents skin
R: 30 usually appear skin condition excoriation and
shortly after frequently, noting breakdown.
birth but may changes or
not be beginning
recognized until breakdown.
Encourage or
later in
assist with
childhood or perineal care
(rarely) in after each bowel
adulthood. In movement.
this order the • Discuss use of • Facilitates
lack of stool softeners, defecation
mild stimulants, when
colorectal enemas as constipated is
innervation
inhibits indicated. Monitor present.
peristalsis, and effectiveness.
the affected
Collaborative:
portion of • Consult with • Fiber resist
intestine dietitian to enzymatic
becomes provide well digestion and
spastic and balanced diet absorbs liquids
contracted. The high in fiber and in its passage
bulk. along the
internal rectal intestinal tract
sphincter fails and thereby
to relay, which produces bulk,
prevents which acts as a
evacuation of stimulant for
defecation.
fecal material
and gas and
causes severe
abdominal
distention and
constipation.