NURSING CARE PLAN
Patient’s Initial: M. F. Sex: Male
Age: 64 y/o
NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective: Constipation related to After 12 hours of nursing Independent: After 12 hours of nursing
> “Ang sakit po ng tiyan ko abdominal muscle intervention, the patient will intervention, the patient
at walong araw na po weakness as evidenced establish or regain normal Determine stool color, Assists in identifying established normal pattern
akong hindi nakaka dumi.” by abdominal distention pattern of bowel consistency, frequency, causative or of bowel functioning;
as patient verbalized. and diffuse tenderness at functioning; verbalize and amount. contributing factors verbalized understanding
> 6/10 pain scale LLQ. understanding of etiology and appropriate of etiology and appropriate
and appropriate interventions. interventions or solutions
Objective: interventions or solutions for individual situation;
> large, rotund, and for individual situation; demonstrated behaviors or
tympanitic abdomen demonstrate behaviors or Auscultate bowel Bowel sounds are lifestyle changes to
(abdominal distention) lifestyle changes to sounds. generally decreased prevent recurrence of
> diffuse tenderness in the prevent recurrence of in constipation. problem; participated in
abdomen (LLQ). problem; participate in bowel program as
> V/S taken and as follows: bowel program as indicated.
indicated. Encourage fluid intake Assists in improving
T – 36.8 C of 2500-3000 ml/day stool consistency.
P – 99 bpm within cardiac
RR – 18 cpm tolerance.
BP – 170/110 mmHg
SpO2 – 97% Recommend avoiding Decrease gastric
gas-forming foods. distress and
abdominal distension.
Assist in perianal skin Prevents skin
condition frequently, excoriation and
noting changes or breakdown.
beginning breakdown.
Discuss use of stool Facilitates defecation
softeners, mild when constipation is
stimulants, bulk- present.
forming laxatives, or
enemas as indicated.
Monitor effectiveness.
Encourage to eat high- To enhance easy
fiber rich foods. defecation.
Dependent:
Administer medications Laxatives are
as indicated recommended when
nonpharmacological
measures such as
behavioral
modification and diet
are ineffective in