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NURS240L Nursing Process Assignment Student Name___________Brian Rose_________

Nursing Care Plan for Priority Nursing Diagnosis Rm#______J.P._____ _____

1 Assessment (Your findings from prep day and days 4 Planned Interventions (Nursing care 5 Rationales
1&2 that relate to the problem. Include dates collected) that will assist to resolve problem. Date when done.) (Why intervention is appropriate, what it accomplishes)
Subjective Objective • Encourage regular intake of food emphasizing foods • The bowels tends to be sluggish after birth because
(Client states r/t problem) (Data) high in fiber i.e. fruits such as raisins, apples and of the lingering affects of progesterone, decreased
bananas, grains and cereals, leafy greens abdominal muscle tone, and bowel evacuation
Client states “I haven’t Client is 2 days P.O. • Assess current activity level and tolerance. Include associated with labor and birth process
had a BM since the my Taking opiate analgesics pain level every two hours and administer analgesics • Change in mealtime, type of food, disruption of
C/S” (Oxycodone) every 4hrs per physician’s orders. usual schedule, and anxiety can lead to constipation.
Client states “the time Client is apprehensive • Prolonged bed rest, lack of exercise, and inactivity
between going to the about ambulation and • Evaluate current medication usage that may contribute to constipation.
bathroom is more than slow in general contribute to constipation. Educate client about side • Opioid analgesics and iron supplements taken
normal” movements even while at effect of use. pre/postpartum can contribute to constipation
bedrest. Possibly related • Women who have had episiotomy, lacerations or
to fear of pain • Evaluate fear of pain hemorrhoids may tend to delay elimination for fear
Intake was 480ml during of possible pain. Delaying bowel movements may
my shift. • Encourage daily fluid intake of 2000 to 3000 ml/day, increase constipation and subsequently cause more
if not contraindicated medically. pain
No BM to date while in
• Dehydration compounds and contributes to
• Encourage ambulation with assist as tolerated. constipation.
Client on REG. diet. • Ambulation strengthen abdominal muscles that
Eating 100% of breakfast facilitate defecation.
• Educate client about a general pattern of constipation
following pregnancy. • Pain relief may reduce anxiety which is associated
with such conditions and promote desire for
• Suggest the following measures to minimize rectal elimination
discomfort: use of Tucks pads to relieve
hemorrhoidal and perineal pain. Use of ice packs to
relive pain associated with episiotomy

2 Nursing Diagnosis
(Problem identified in assessment)
Impaction; obstipation r/t pregnancy d/t decreased
mobility and use of opioid analgesics. Reference w/page #s: Nursing Care Plan pg 46-48 Old’s
pg 1045
3 Outcomes (Specific to client & Nsg Dx, realistic, measurable, and time limited with baseline 6 Evaluation (Were outcomes accomplished? If not, why)
data in Assessment) Date & Time:
Client will verbalize at least 3 means of promoting peristalsis by end of shift On 4/16/10 at 0830, Client met outcome by stating “drinking plenty of water,
4/16/10. eating foods high in fiber, and getting out of bed and moving around”
Criteria for Nursing Process Assignment
1. Assessment
1. Is subjective data in the client’s or significant other’s own words or accurately paraphrased?
2. Is objective data in the form of specific measurements from student’s assessment (ie, resp rate, breath
sounds, wound measurement, etc) and diagnostic information from the chart? Are dates included? Subjective
3. Does data relate ONLY to the problem identified in nursing diagnosis?
4. Does data adequately support the nursing diagnosis or is additional data needed? Objective
2. Nursing Diagnosis
1. Does the nursing diagnosis accurately describe the problem or risk identified in the assessment? Nursing Diagnosis
2. Is the nursing diagnosis NANDA?
3. Does the “related to” section describe the etiology (cause) of the problem (in physiological terms)?
4. If “high risk for” diagnosis, are the risk factors listed instead of “related to” section?
3. Outcomes (Use action verbs only. You must be able to use outcomes in the evaluation step to measure
client’s response to nursing interventions.)
1. Are outcomes specific, realistic, measurable and have an appropriate and realistic time limit? Outcomes
2. Are there baseline measurements for all outcomes in the assessment?
3. Do outcomes demonstrate improvement or at least no worsening of the problems?
4. Do outcomes reflect changes expected as the result of nursing interventions?
4. Interventions: List references (Text & page#)
1. Do nursing interventions address the identified problem?
2. Do interventions help resolve the problem? Interventions
3. Do interventions best accomplish the outcomes?
4. Are interventions individualized to client (“O2 as ordered” would not be individualized but “O2 at 2L
per NC” would be.)
5. Are interventions specific enough? (“Increased activity” would not be specific but “Walk length of
hallway qid” would be.)
6. Are references listed?
7. Have interventions been done? Date when done added to intervention?
5. Rationales
1. Do rationales explain why the intervention is appropriate to resolve the problem? Rationales
2. Do rationales explain what the rationale accomplishes?
6. Evaluation (Determines effectiveness of plan of care and addresses outcomes.
1. Were outcomes evaluated by reassessment? Evaluation
2. Were specific findings reassessed and listed?
3. Did the outcome (change) occur? Were outcomes met? If not, why?