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    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

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    Yamete Kudasai
    The patient reported not having a bowel movement for a long time and feeling restless and irritable. The nurse assessed for constipation related to lack of physical activity. The nursing plan was to encourage fluid intake, fiber consumption, responding to the urge to defecate, and maintaining privacy. Within 8 hours, the patient was able to have soft, regular bowel movements and the goal was met.

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    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

    Uploaded by

    Yamete Kudasai
    13 views2 pages
    The patient reported not having a bowel movement for a long time and feeling restless and irritable. The nurse assessed for constipation related to lack of physical activity. The nursing plan was to encourage fluid intake, fiber consumption, responding to the urge to defecate, and maintaining privacy. Within 8 hours, the patient was able to have soft, regular bowel movements and the goal was met.

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    NCP-Misanes

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    The patient reported not having a bowel movement for a long time and feeling restless and irritable. The nurse assessed for constipation related to lack of physical activity. The nursing plan was to encourage fluid intake, fiber consumption, responding to the urge to defecate, and maintaining privacy. Within 8 hours, the patient was able to have soft, regular bowel movements and the goal was met.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views2 pages

    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

    Uploaded by

    Yamete Kudasai
    The patient reported not having a bowel movement for a long time and feeling restless and irritable. The nurse assessed for constipation related to lack of physical activity. The nursing plan was to encourage fluid intake, fiber consumption, responding to the urge to defecate, and maintaining privacy. Within 8 hours, the patient was able to have soft, regular bowel movements and the goal was met.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

    DIAGNOSIS

    S: “I am sleepless
    because my knees and Pain related to Within 8hours of Assess patient signs and symptoms The guarding behavior of acute pain After 8 hours of
    associated with agitation, may become a persistent change in
    ankles hurt” Disease Process nursing irritability, and sleep disturbance body posture for the patient with nursing
    interventions, chronic pain. interventions,
    O: Patient reports pain Patient has reported
    -swelling knees and at a level less than 3 Assess the patient’s beliefs and Patients with chronic pain may not pain at a level less
    expectations about pain relief. anticipate complete relief of pain but
    ankles to 4 on a 0 to 10 may be satisfied with diminishing
    than 3 to 4 on a 0 to
    - irritable rating scale. severity of the pain and increasing 10 rating scale.
    activity level.
    Evaluate the patient’s approach Patients may perceive medications as
    towards pharmacological and the only effective treatment to
    Goal Met.
    nonpharmacological means of pain alleviate pain and may question the
    management. effectiveness of nonpharmacological
    interventions.

    If opioid dose is increased, Patients receiving long-term opioid


    monitor sedation and respiratory therapy generally develop tolerance
    status for a brief time. to the respiratory depressant effects
    of these agents.
    Implement nonpharmacological Nonpharmacological interventions
    interventions when pain is should be used to reinforce, not
    relatively well controlled with replace, pharmacological
    pharmacological interventions. interventions.

    Plan care activities around periods Pain diminishes activity.


    of greatest comfort whenever
    possible.
    ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
    DIAGNOSIS

    S: “I have not
    defecated for a long Constipation related Within 8hours of Check on the usual pattern of The normal frequency of stool After 8 hours of
    elimination, including frequency passage ranges from twice daily to
    time now” to Lack of Physical nursing and consistency of stool. once every third or fourth day. nursing
    Activity interventions, activity level. interventions,
    O: restless, agitated, Patient maintains Check out usual dietary habits, Irregular mealtime, type of food, and Patient verbalizes
    irritable passage of soft, eating habits, eating schedule, and interruption of usual schedule can maintenance
    liquid intake. lead to constipation.
    formed stool at a passage of soft,
    frequency perceived Encourage the patient to take in Sufficient fluid is needed to keep the formed stool at a
    as “normal” by the fluid 2000 to 3000 mL/day, if not fecal mass soft. . frequency perceived
    patient. contraindicated medically. as “normal” by the
    patient.
    Assist patient to take at least 20 g Fiber adds bulk to the stool and
    of dietary fiber (e.g., raw fruits, makes defecation easier because it
    fresh vegetable, whole grains) per passes through the intestine
    day. essentially Goal Met.
    Consider the degree to which the Ignoring the urge to defecate
    patient responds to the urge to eventually leads to chronic
    defecate. constipation because the rectum no
    longer senses or responds to the
    presence of stool.

    Feel the need for privacy for Defecating is a private thing. Most
    elimination. patients may have a hard time having
    a bowel movement away from the
    sense of privacy in their home.

    Classify current medications usage A lot of drugs can slow down


    that may lead to constipation. peristalsis. Opioids, antacids with
    calcium or aluminum base,
    antidepressants, anticholinergics,
    antihypertensives, etc.

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