Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

PRIORITIZATION TABLE FOR THE IDENTIFIED NURSING PROBLEMS

Patient’s Initial: R.S. Age: 50 y/o Gender: Male Date Handled: October 27 2022

Medical Diagnosis: Ileostomy Chief Complaint: Clinical Area: Surgical Ward

Level of Date Identified Assessment Cues Nursing Diagnoses Justifications / Bases in Prioritizing the Problem
Priority
I Subjective: Constipation related to This has been the priority among all problem because, from the given scenario
inflammation within bowel and the patient is already showing manifestations of constipation with date being
Abdominal pain; pain with malabsorption as evidenced by provided. As this problem being the priority, possible complications of the
abdominal pain and liquid fecal current illness of the patient will be avoided to be happened.
defecation; nausea;
particles.
vomiting; headache;
indigestion; generalized
fatigue
Objective:

Vital signs BP 130/90

mm/hg
PR 78
RR-18
O2 sat.98%

II Subjective: Disturbed body image related to Body image is how a person feels about his or her body and what they do about
loss of control of bowel those feelings. Some may feel inferior about their bodies and try to improve
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
Objective: elimination as evidence by actual them through a variety of means called appearance management behaviors. As a
change in structure and function significant component of one’s self-concept, body image disturbance can have
of ostomy. an intense impression on how individuals see their overall selves. Physical
changes associated with aging may result in body image disturbance for the
older adult. Personality traits such as perfectionism and self-criticism can also
affect the development of a negative internalized image of the body.
III Subjective: Acute pain related to physical The unpleasant feeling of pain is highly subjective in nature that may be
factors e.g disruption of experienced by the patient. The International Association for the Study of Pain
Objective: skin/tissues as evidenced by (IASP) defined pain as “an unpleasant sensory and emotional experience
reports of pain. associated with actual or potential tissue damage, or described in terms of such
damage.” Another great and influential definition of pain is from Margo
McCaffery, a nurse expert on pain, who defined it as “pain is whatever the
person says it is and exists whenever the person says it does.”
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: R.S Age: 50 y/o Gender: Male Date Handled: October 27 2022

Medical Diagnosis: Ileostomy Chief Complaint: Clinical Area: Surgical Ward

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Constipation related to Short Term Goal: Independent: Short Term Evaluation:
inflammation within bowel
and malabsorption as
 Abdominal pain; evidenced by abdominal After 1-2 hours of nursing  Review medical, surgical,  To identify In a span of 1-2 hours,
 pain with pain and liquid fecal intervention the patient will and social history conditions the goal to show an
defecation; particles. show an improvement in commonly improvement in
 nausea; constipation as manifested associated with constipation was
 vomiting; by: constipation
Partially Met.
 headache;  Note color, odor,  Provides a baseline
1. Occasionally abdominal
As evidenced by:
 indigestion; consistency, amount, and for comparison,
1. Occasionally abdominal
cramping frequency of stool promotes
 generalized fatigue cramping
2. relieved from nausea, recognition of
2. relieved from nausea,
vomiting as well headache. changes.
vomiting as well headache.
3. Minimal pain when  Encourage client to  To facilitate 3. Minimal pain when
defecating. maintain elimination diary, monitoring of long- defecating.
if appropriate term problem.
 Note client’s age  Many older adults
experience Long Term Evaluation:
constipation as a
result of duller
nerve sensations,
immobility,
dehydration and
electrolyte
imbalances;
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
incomplete
emptying of the
bowel, or failing to
attend to signals to
defecate.

 Determine fluid intake.  Most individuals

Objective: do not drink
enough fluids,
Long Term Goal: even when
healthy, reducing
the speed at
which stool
moves through
the colon. Active
fluid loss through
sweating,
vomiting,
diarrhea, or
bleeding can
greatly increase
chances for
constipation
Dependent:
 To easily promote
VS After 1 weeks of nursing  Administer medication In a span of 1 week of
BP 130/90 mm/hg intervention the patient will healing for the continuous nursing
as indicated by the doctor.
PR 78 show an absence of patient. interventions the goal to
(Example proton loop
RR 18 constipation as manifested  To maintain show an absence of
O2 Sat. 98% by: inhibitors)
healthy nutrition constipation was MET.
1. Verbalizing having a  Promote adequate
and promote
bowel movement without nutrition as per the As evidence by:
faster healing.
straining Nutrionist guidelines 1. Verbalizing having a
2. Relive from constipation bowel movement without
3. Bowel movements 2-3 straining
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
days Interdependent/ 2. Relive from constipation
Collaborative: 3. Bowel movements 2-3
days
 Took a fecal output for
 To tests for any
diagnostics
other
 Refer to
complications
gastroenterologist for
aligned in the
examining the stool
current condition
of the patient.
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

DRUG STUDY

Patient’s Initial: R.S Age: 50 Gender: Male Date Handled: October 27 2022

Medical Diagnosis: Ileostomy Chief Complaint: Clinical Area: Surgical Ward

Medication Date Ordered/ Route of Mechanism Indications Contraindications Client’s Response Nursing

Given/Taken/ Administration/ of Responsibilities

Discontinued Dosage/Frequency Actions

Generic: Date ordered: Route: Inhibits hydrogen- This drug is indicated to: This drug is The following Prior:

 Omeprazole  N/A  PO potassium adenosine contraindicated to the manifestations are  Check if the patient
triphosphatase I. Erosive following: the anticipated has an adverse
Brand: Dosage:
(H1/K1 ATP pump), Esophagitis I. Hypersensitivity therapeutic and reaction to
 Prilosec Date given or  20mg
an enzyme on the II. Poorly to the drug or non-therapeutic omeprazole and its
Classification: taken: Frequency: surface of gastric Responsive any excipients responses of the components.
 Proton  N/A  Two parietal cells. III. Gastroesophagea from the dosage patient.  Wash hands and wear
Pump time a Therapeutic Effect: l Reflux Disease form THERAPEUTIC PPE if needed as per
Increases gastric pH, (GERD), II. Patients taking This drug has not the hospital protocol.
Inhibitors Date day
reduces gastric acid IV. Active Duodenal dosage forms any therapeutic
discontinued:  Assess whether the
production. Ulcer, containing effect based from
client has certain
 N/A
V. Prevention/ apomorphine. the given scenario
conditions that may
Treatment of however, it is
affect the
NSAID-Induced expected theoretically
effectiveness of this
Ulcers that the patient will
drug or will
Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
Precaution is indicated have an adverse or toxic contradict its effect.
such as: reactions such as  Prepare the
I. Mild to moderate pancreatitis, medication
hepatic hepatotoxicity, and  Check for its
impairment interstitial nephritis that expiration
II. Pts at risk for QT occurs rarely.  Gather and align all
prolongation or NON- the necessary
ventricular THERAPEUTICS materials that will aid
arrhythmia The patient experienced in giving the
(congenital long frequent headache, medication.
QT prolongation occasional diarrhea,
III. Medications abdominal pain, nausea.
prolonging QT And in some rare cases
interval dizziness, asthenia
IV. Hypokalemia, (loss of strength, During:

hypomagnesemia) energy), vomiting,  Position the

. constipation, upper patient to an
respiratory tract accurate and
infection, back pain,
comfortable
rash, cough.
position.

 Administer the

medication to the

right patient

with right
Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
dosage,

frequency and

route.

 Ask the patient if

he/she needs an

assistance in

taking the

medicine.

PO:

 ✓ Ensure that the

patient will drink

and take the

medicine.

 ✓ Offer a glass of

water to the

patient if needed.

After:
Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
 Gather all the used

materials in giving

the medication and

set aside.

 Evaluate for

therapeutic

response (relief of

GI ymptoms).

Question if GI

discomfort,

nausea, diarrhea

occurs.

 Watch for

manifestations of

hepatotoxicity

 Perform a health

teaching to the

patient if

applicable; instill

the possible

adverse effect that

Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan
needs to be aided

by a physician. As

well as the

manifestations of

the complications

that needs an

urgent attention.

 Instruct the patient

to take the medicine

whole

 Instruct the patient

to take medicine

before eating