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RLE FORM 002 Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and

Compassion

NURSING CARE PLAN

NCP Scoring System Nursing Dx

10 pts 2 pts

Defining Characteristics Outcome

3 pts 1 pt

Intervention Bibliography

3 pts 1 pt (at least 5 references)

Client s Name: ________S.C_________________________________ Age: _54__ Civil Status: ____Married_ Religion: __Roman Catholic___ Allergies: Food: _______none known_____________________________ Drug: ____none known_____________________________ ___________________________ Diet: _blenderized feeding Date of Admission: ___6/17/2011_________________________________ Diagnosis _PTB with Pneumoinia, R/I Tabes Mesenterica, Anemia of_____ _________Chronic Illness, R/O UGIB 2 to BPUD ____________________ DEFINING CHARACTERISTICS Nursing Diagnosis: Constipation related to decreased motility of gastrointestinal tract S: 4 na kaadlaw wala kalibang verbalized by the patient s SO as EXPECTED OUTCOME CRITERIA (Ideal) Short term Goal: Within 8hrs of nursing interventions, the patient and his SO will verbalize understanding of etiology and appropriate interventions/solutions for individual situation

Patient Care Classification: (Please Check) ___/_ ____ Wholly Compensatory: Pts. therapeutic self-care is accomplished by nurse __________ Partially Compensatory: Pts. performs some self-care measures __________ Supportive Educative: Pts accomplishes self-care measures Clinical Division and Bed No: ____X-22______________________________________ Name of Physician: _Dr. Ababon ___________________________________________ Name of Student: __Fat, Demilyn O.________________________________________ INTERVENTION AND RATIONALE Independent: I: Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; surgeries; alterations in perianal sensation; present bowel regimen. R: There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination. (Doenges et al, 2006,p157) BEHAVIORAL OUTCOME (ACTUAL)

O:Awake, conscious and coherent :hypoactive bowel sounds upon auscultation :abdominal tenderness without palpable muscle resistance noted :

Long term Goal: Within 2-3days of nursing interventions, the patient will establish/regain normal pattern of bowel functioning

DEFINING CHARACTERISTICS Laboratory:

EXPECTED OUTCOME CRITERIA (Ideal) Independent interventions cont. I: Determine client's perception of normal bowel elimination; promote adherence to a regular schedule. R: Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives. (Doenges et al, 2006,p157) I: Provide rest periods to facilitate comfort, sleep, and relaxation. R: The patient s experiences of pain may become exaggerated as the result of fatigue (Gulanick et al, 2010) I: Explain Valsalva's maneuver and the reason it should be avoided. R: Valsalva s maneuver can cause bradycardia and even death in cardiac patients.. (Gulanick et al, 2010) I: Provide relaxation techniques like deep breathing exercises R: Techniques are used to bring about a state of physical and mental awareness and tranquillity that reduces tension, subsequently promoting relaxation of muscles. (Gulanick et al, 2010)

INTERVENTION AND RATIONALE I: Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). R: Adequate fluid intake is necessary to prevent hard, dry stools. (Doenges et al, 2006,p157) I: Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths. RActivity, even minimal, increases peristalsis, which is necessary to prevent constipation. (Doenges et al, 2006,p157) I: Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool. R: Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly (Doenges et al, 2006,p157))

BEHAVIORAL OUTCOME (ACTUAL)

Theoretical Basis: Constipation is the decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool. In the elderly, causes include: insufficient dietary fiber intake, inadequate fluid intake, decreased physical activity, side effects of medications, , and obstruction by colorectal cancer. Constipation occurs when the colon absorbs too much water or if the colon s muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry. Not having enough fiber in the diet, lack of physical activity, not enough liquids, medications, and changes in life are just some of the factors that affect the patient and subsequently contributing to the constipation. (http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/)

I: Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice R: Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. (Doenges et al, 2006,p157)

Bibliography: >Doenges et al.2006. Nursing Care Plans. 7th Ed. Lippincott Williams and Wilkins. Philadelphia >Doenges et al.2009.Nurse s Pocket Guide.10th Ed. Lippincott Williams and Wilkins. Philadelphia >Gulanick et al.2010. Nursing Care Plans. Accessed on May 10,2011 at http://www1.us.elsevierhealth.com/MERLIN/ Gulanick/Constructor/index.cfm?plan=40 > Constipation.National Digestive Diseases Clearing House.(http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/)

Dependent/Collaborative: I: Provide laxatives, suppositories, and enemas as needed and as ordered only R: To facilitate evacuation of colonic contents (Doenges et al, 2006,p157)