Nursing Care Plan Assessment Subjective data: Diagnosis Planning/ goal Patient wil maintain position of comfort and

pain during period of admission Urine output will be greater than 30ml/hr. Patient will pass flatus and small formed brown stool with negative occult blood Patient will verbalized feeling better at the end of admission Intervention  Encourage well balanced and high fiber diet.  Encourage regular exercise  Encourage for regular chek up  Insert an NG tube as ordered by physician  Maintain function of NG tube  Assess and measure the nasogastric output  Maintain fluid and electrolyte balance by monitoring electrolyte, blood urea nitrogen and creatinine level rational  increases the size and weight of stools as well as softening them.  helps to maintain normal bowel movements  To avoid complications  to decompress the bowel to relieve vomiting and distension  Promote proper treatment  Documentation provides accurate record  To maintain electrolyte and fluid balance evaluation Maintain position of comfort, states pain decreased to 3 or 4 level on 0-10 scale Urine output greater than 30ml/hr.; vital signs stable Passed flatus and small, formed brown stool, negative occult blood Respirations 12-18 breaths per minute and unlaboured with head of bed elevated 45 degrees Alert, vital signs stable, abdomen firm Appears relaxed and reports feeling better

Acute pain related to Patient stated obstruction, having abdominal distension, and pain strangulation of intestinal tissue

Objective data: Patient stated that he vomited 2 times before coming to hospital

Risk for deficient Fluid volume related to impaired fluid intake, vomiting, and diarrhea from intestinal obstruction

. Begin and maintain IV therapy as ordered  Monitor nutritional status  To replace fluids and electrolytes  To adapt therapy to pt’s need  Continually assess his pain. passage of flatus or stool).  Colicky pain that suddenly becomes constant could signal perforation  Continuous assessment is necessary to assess effectiveness of therapy  Assess improvement( return of normal bowel sounds. decreased abdominal distension. subjective improvement in abdominal pain and tenderness.

dry cracked lips. swollen tongue.  To assess effectiveness of Iv therapy  To assess effectiveness of therapy  Watch for sings and symptoms of secondary infection. such as fever and chills. and increased nasogastric output. worsening of pain or abdominal distension. dry oral mucous membranes)  Watch for signs of metabolic alkalosis  Report discrepancies in intake and output.  Administer analgesics( avoid opiate due to GI  To prevent complications  To decrease pain of the patient Achieving pain . Look for signs of dehydration( thick.

motility inhibition).  If the pt. in semi-fowler’s or fowler’s position as much as possible. broadspectrum antibiotics. for surgery.’s condition does not improve prepare pt.  Monitor urine output carefully. and other medications as prescribed. focusing on his type of intestinal  To alleviate stress due to current condition. relief  These positions help to promote pulmonary ventilation and ease respiratory distress from abdominal distension  Possible urine retention due to bladder compression by the distended intestine may occur.  Teach the patient about his disorder.  Keep the pt. .

its cause.obstruction. and signs and symptoms. .