NURS240L Nursing Process Assignment Nursing Care Plan for Priority Nursing Diagnosis 1

Student Name___________Brian Rose_________ Rm#______J.P._____ _____ 4

Assessment (Your findings from prep day and days 1&2 that relate to the problem. Include dates collected)
Subjective Objective
(Data)

Planned Interventions (Nursing care that will assist to resolve problem. Date when done.)
Encourage regular intake of food emphasizing foods high in fiber i.e. fruits such as raisins, apples and bananas, grains and cereals, leafy greens Assess current activity level and tolerance. Include pain level every two hours and administer analgesics per physician’s orders. Evaluate current medication usage that may contribute to constipation. Educate client about side effect of use. Evaluate fear of pain Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. Encourage ambulation with assist as tolerated. Educate client about a general pattern of constipation following pregnancy. Suggest the following measures to minimize rectal discomfort: use of Tucks pads to relieve hemorrhoidal and perineal pain. Use of ice packs to relive pain associated with episiotomy

5

Rationales
(Why intervention is appropriate, what it accomplishes)

(Client states r/t problem)


Client states “I haven’t had a BM since the my C/S” Client states “the time between going to the bathroom is more than normal”

Client is 2 days P.O. Taking opiate analgesics (Oxycodone) every 4hrs Client is apprehensive about ambulation and slow in general movements even while at bedrest. Possibly related to fear of pain Intake was 480ml during my shift. No BM to date while in postpartum. Client on REG. diet. Eating 100% of breakfast

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The bowels tends to be sluggish after birth because of the lingering affects of progesterone, decreased abdominal muscle tone, and bowel evacuation associated with labor and birth process Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation. Prolonged bed rest, lack of exercise, and inactivity contribute to constipation. Opioid analgesics and iron supplements taken pre/postpartum can contribute to constipation Women who have had episiotomy, lacerations or hemorrhoids may tend to delay elimination for fear of possible pain. Delaying bowel movements may increase constipation and subsequently cause more pain Dehydration compounds and contributes to constipation. Ambulation strengthen abdominal muscles that facilitate defecation. Pain relief may reduce anxiety which is associated with such conditions and promote desire for elimination

2

Nursing Diagnosis
(Problem identified in assessment)

Impaction; obstipation r/t pregnancy d/t decreased mobility and use of opioid analgesics. 3 Outcomes

Reference w/page #s: Nursing Care Plan pg 46-48 Old’s pg 1045

(Specific to client & Nsg Dx, realistic, measurable, and time limited with baseline data in Assessment)

6

Evaluation (Were outcomes accomplished? If not, why) Date & Time:

Client will verbalize at least 3 means of promoting peristalsis by end of shift 4/16/10.

On 4/16/10 at 0830, Client met outcome by stating “drinking plenty of water, eating foods high in fiber, and getting out of bed and moving around”

Criteria for Nursing Process Assignment
1. Assessment 1. Is subjective data in the client’s or significant other’s own words or accurately paraphrased? 2. Is objective data in the form of specific measurements from student’s assessment (ie, resp rate, breath sounds, wound measurement, etc) and diagnostic information from the chart? Are dates included? 3. Does data relate ONLY to the problem identified in nursing diagnosis? 4. Does data adequately support the nursing diagnosis or is additional data needed? 2. Nursing Diagnosis 1. Does the nursing diagnosis accurately describe the problem or risk identified in the assessment? 2. Is the nursing diagnosis NANDA? 3. Does the “related to” section describe the etiology (cause) of the problem (in physiological terms)? 4. If “high risk for” diagnosis, are the risk factors listed instead of “related to” section? 3. Outcomes (Use action verbs only. You must be able to use outcomes in the evaluation step to measure client’s response to nursing interventions.) 1. Are outcomes specific, realistic, measurable and have an appropriate and realistic time limit? 2. Are there baseline measurements for all outcomes in the assessment? 3. Do outcomes demonstrate improvement or at least no worsening of the problems? 4. Do outcomes reflect changes expected as the result of nursing interventions? 4. Interventions: List references (Text & page#) 1. Do nursing interventions address the identified problem? 2. Do interventions help resolve the problem? 3. Do interventions best accomplish the outcomes? 4. Are interventions individualized to client (“O2 as ordered” would not be individualized but “O2 at 2L per NC” would be.) 5. Are interventions specific enough? (“Increased activity” would not be specific but “Walk length of hallway qid” would be.) 6. Are references listed? 7. Have interventions been done? Date when done added to intervention? 5. Rationales 1. Do rationales explain why the intervention is appropriate to resolve the problem? 2. Do rationales explain what the rationale accomplishes? 6. Evaluation (Determines effectiveness of plan of care and addresses outcomes. 1. Were outcomes evaluated by reassessment? 2. Were specific findings reassessed and listed? 3. Did the outcome (change) occur? Were outcomes met? If not, why?

Subjective Objective Nursing Diagnosis

Outcomes

Interventions

Rationales Evaluation

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