ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION

S:Nakakainom
ako ng tubig
hanggang
limang baso sa
isang araw.
Madalas pa rin
akong umihi,
mga 5to 7
times, pero
ang pagdumi
ko ay hindi na
araw araw. as
verbalized.

O> Dry lips
>Bowel sounds
: RUQ; 4,LUQ,-
4 RLQ,-3 , LLQ-
4
>pail nail beds
and capillary
refill of 2 secs
>dry cracked
heels
>brown and
well-formed
stool

Risk for
constipation
related to
decreased fluid
intake

Insufficient intake
of fluids within
the day can cause
decrease in
frequency of
defecation. It can
be accompanied
by difficult
passage of stool,
or excessively dry
and hard stool.

Short-term goal:
After 8 hours of
nursing
interventions, the
client will be able
to maintain usual
pattern of bowel
functioning.

Long-term goal:
After 3 days of
nursing
interventions, the
client will be able
to demonstrate
lifestyle changes
to prevent the
risk of
constipation.

Objectives:
After 8 hours of
nursing
interventions, the
client will be able
to :
Verbalize
understandin
g of risk
factors and
appropriate
interventions
Independent:
1. Assess the
condition of the
patient.

2. Review medical
and social history
of the patient.

3. Instruct the client
to increase fiber
and bulk in the
diet like fruits and
vegetables.

4. Promote
adequate fluid
intake including
water and high-
fiber fruit juices.

5. Discuss the
physiology in
elimination and its
risk factors.

6. Encourage activity
and exercise
according to the
clients tolerance
level.

7. Encourage client

1.To provide baseline
information.


2. To identify risk and
contributing factors.


3. Increased fiber will
improve the consistency
of stool and facilitate
passage through the
colon.

4. Adequate fluids will
promote soft stool and
stimulate bowel activity.



5. To provide the client
understanding about
constipation and his
condition.

6. To stimulate
contractions of the
intestines.



7. To include patient in the

Short-term goal:
After 8 hours of
nursing
interventions, the
client defecated
once with brown
well-formed stool
with ease.

Long-term goal:
After 3 days of
nursing
interventions, the
client was able to
participate in the
plan of care and
demonstrate
lifestyle changes that
reduced the risk of
constipation.

>yellow urine


related to the
situation.
Participate in
the plan of
care.
to maintain
elimination diary.

Dependent:
1. Administer laxatives
and enema as
prescribed by the
doctor.

Collaborative:
1. Include the family in
the plan of care.
care and to help
monitor bowel pattern.


1. Laxatives and enema
will help in bowel
elimination with ease.



1. Providing family in the
health care will promote
holistic care for the
patient.