CAREPLAN
 
Nursing   Expected​ ​Patient  Assessment  Action  Teaching 
Diagnoses  Outcomes  interventions  interventions  interventions 

Chronic​ ​functional
Constipation
R/T
-Irritable​ ​Bowel
Syndrome​ ​(Ulcerative
Colitis)
AEB
-prolonged​ ​straining
when​ ​trying​ ​to​ ​defecate prevent/treat
(​ ​>50%​ ​of​ ​the​ ​time)
-positive​ f​ ecal​ ​occult
blood​ ​test
-hypoactive​ ​bowel
sounds​ ​(bowel​ ​sounds
barely​ ​audible​ ​in​ ​1/4
abdominal​ ​quadrants)
Patient​ ​will​ ​maintain Monitor​ ​diet​ ​intake Implement​ ​a​ ​toileting Fiber​ ​intake​ ​of​ ​18​ ​to
passage​ ​of​ ​soft, program​ ​to​ ​develop 25g​ ​per​ ​day​ ​(leafy
formed​ ​stool​ ​every​ ​1-3 routine​ ​bathroom greens,​ ​whole​ ​grains)
days​ ​without​ ​straining Monitor​ B ​ M​ ​frequency, breaks​ ​(after​ ​waking
by​ ​11/20/2017. consistency​ ​and up,​ ​after​ ​meals,​ ​after
amount exercise,​ ​etc.) Encourage​ ​patient​ ​to
keep​ ​a​ ​seven​ ​day​ ​day
Patient​ ​will​ ​identify​ ​two diary​ ​of​ ​bowel​ ​habits
measures​ ​that Assess Encourage​ ​physical (include​ ​time​ ​of​ ​day,
medications/PMH​ ​to activity​ ​(take​ ​walks length​ ​of​ ​time​ ​on​ ​toilet,
constipation​ ​by see​ ​what​ ​may​ ​be outside) any​ ​straining,
10/30/2017. affecting​ ​bowel​ ​health consistency,​ ​amount
and​ ​frequency​ ​of
stool)

Risk​ ​for​ ​Falls
R/T
-age
-history​ ​of​ ​falls
-SOB/fatigue​ ​upon
prolonged​ ​exertion
(COPD)
Patient​ ​will​ ​remain
free​ ​from​ ​falls​ ​for​ ​two
weeks​ ​by​ ​11/10/2017
Patient​ ​will
demonstrate
knowledge​ ​of​ ​three
effective​ ​methods​ ​to
prevent​ ​injury/falls​ ​by
10/30/2017
Monitor​ ​patient’s​ ​gait,
fatigue,​ ​balance​ ​upon
ambulation
Evaluate​ ​patient’s
medications​ ​to
determine​ ​if​ ​they
increase​ ​fall​ ​risk
Make​ ​sure​ ​that​ ​call
bell​ ​is​ ​in​ ​reach​ ​when
leaving​ ​patient​ ​and
answer​ ​call​ ​light
promptly
Assist​ ​patient​ ​with
ambulation--orient
them​ ​to​ ​environment
beforehand.
Avoid​ ​attending​ ​to
other​ ​tasks​ ​while
ambulating​ ​(i.e.
holding​ ​a​ ​cup)
Rise​ ​slowly​ ​out​ ​of​ ​bed
to​ ​avoid​ ​orthostatic
hypotension
Make​ ​use​ ​of​ ​assistive
devices​ ​(RW)​ ​correctly
and​ ​transfer​ ​safely

Eliminate​ ​clutter