Chinese General Hospital College of Nursing and Liberal Arts Nursing Care Plan Magdangal, Nikki Isobelle A.
PATIENTS NAME: JQ Assessment Subjective: The patient reports abdominal pain and difficulty in defecation on previous assessment. II-A AGE: 64 Plan Short-term goal After 30 minutes of nursing intervention the patient will:
AREA/ROOM: 5A (520) Intervention Independent: Monitor vital signs and pain level every hour Rationale
Diverticulosis Evaluation Short-term: After 30 minutes of nursing intervention, the goal is met. The patient was able to: increase comfort and rest Verbalize understanding of the recommended high-fiber diet and fluid intake to promote optimal bowel function
Diagnosis Nursing diagnosis: Constipation related to change in normal bowel habits characterized by a decrease in stool frequency and the emission of hard, dry stools. Inference: Diverticula are herniations/saclike outpouchings of mucosa through the muscle layers of the colon wall. Diverticulosis is asymptomatic diverticular disease. Diverticulitis represents inflammation. Most common in individuals over 60 years of age, particularly those where much of the diet consists of refined foods. Characterized by inflammation of segments of the GI
increase comfort and rest Verbalize understanding of the recommended high-fiber diet and fluid intake to promote optimal bowel function verbalize relief from pain from 8 to 5
Objective: Vital signs: BP= 140/80 PR=98 RR=22 T=36.7 IVF: PNSS 1L @ 40gtts/min via right metacarpal vein FC connected to urine bag with bloody urine output amounting to 30cc/hr. collected Q1o Nasal cannula @ 1lpm
For baseline record. Fever, increase pain and tenderness may indicate infection, abscess formation, or perforation. Notify physician if these symptoms occur
Keep client on bed rest
Promotes resting the bowel and promotion of healing Provides information about fluid intake, hydration, dietary needs and effectiveness of therapy Education of client promotes cooperation with
Measure intake and output; weigh daily.
Patient had verbalized adequate pain relief Pain scale from 8 to 5 Vital sign: BP=140/80; PR=98; RR=20
Educate the client to notify staff of chills, fever,
Awake Coherent abdominal tenderness left side of lower abdomen (LLQ) cramping constipation leukocytosis stool: (usual pattern) frequency =once a day characteri stic =formed, moist color =light-dark brown pain scale (abdominal pain) =7/10 Weight =175lbs.
tract, mot frequently in the sigmoid colon. The inflammation involves all layers of the bowel wall. The areas of involvement are usually discontinuous with segments of normal bowel occurring between diseased portions. The outpouches of mucosa appear as slit-like openings from the mucosa surface of an opened bowel. The diverticula from at weak points in the color wall, usually where arteries penetrate the tunica muscularis to nourish the mucosal layer. The colonic mucosa herniates through the smooth muscle layer. A common associated finding is thickening of the circular and longitudinal (teniae coli) muscles surrounding the diverticula. Hypertrophy and contraction of these muscles increases intraluminal pressure and degree of herniation. Habitual consumption of a lowresidue diet reduces
Long-term goal After a day of nursing intervention, the patient will attain: normal elimination @ least once a day Maintain adequate nutrition and fluid intake as demonstrated by balanced intake and output, stable weight, good skin turgor and mucous membrane moisture, and laboratory values within the normal range. verbalize relief from pain from 5 to 2
shortness of breath, or increasing pain
treatment and enhances healing and recovery
Long-term: After a day of nursing intervention, the goal is partially met. The patient was able to attain: normal elimination @ least 1 times a day Maintain adequate nutrition and fluid intake as demonstrated by balanced intake and output, stable weight, good skin turgor and mucous membrane moisture, and laboratory values within the normal range.
Allow client to verbalize feelings (emotional, psychological and spiritual)
Establishes therapeutic relationship with client to assist in identifying problems causing stress, anxiety, and feelings of powerlessness
Health teaching: Diet = foods high in fiber ROM exercise adequately
To gain knowledge on how to manage constipation
Dependent: administer IV fluid and electrolyte replacement as ordered IV fluids and electrolyte replacement per IV fluids mau b needed based on lab results and need for hydration during periods of disease exacerbation Promotes resting the bowel and promotion of healing
Patient had verbalized relief from pain from 5 to 2
Keep client on NPO status as indicated and ordered
fecal bulk, thus reducing the diameter of the colon. Wall pressure increases as the diameter of cylindrical structure decreases so pressure within the narrow lumen can rupture the diverticula possibly leading to abscess formation or peritonitis.
Administer medication as prescribed
Medication are given to control pain and other symptoms
Hyoscine-Nbutylbromide (Buscopan) 10mg/ tab TID Metoclopramide (Plasil) 1amp/ IV Q8o PRN Aeknil (Paracetamol) 500 mg/ tab Q4o
