GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION INC.

NCM: 112n RLE EXPOSURE

Area: GSDH WARD
Patient: Ms. Cora Loy
Age and Sex: 69/Female
Chief Complaint: Constipation x6 days
ASSESSMENT
Subjective Cues:
“maglisud ko ug tae unom ka
adlaw na ug grabe kaayo
akong singot” as verbalized by
patient.
Objective Cues:
-Infrequent passage of stool
-abdominal distention
-Profuse sweating
Attending Physician: Dr. Zoo
Diagnosis: Constipation
DIAGNOSIS AND INFERENCE
Ng Dx:
Decrease in normal
frequency of defecation
accompanied by difficult
passage of stool.
Inference/ Background
Knowledge:
Constipation is common
especially among older
patients. The obvious culprits
include a low fiber diet,
repeatedly ignoring the urge
to go, not drinking enough
water, or a lack of exercise.
Also, the use of medications,
especially opioid analgesics,
and overuse of enemas and
laxatives, can cause
constipation. Certain
psychological disorders like
stress and depression can
also cause such condition.
Reference:
https://nurseslabs.com/cons
tipation/
Inclusive Dates:
Students Name: Kusain, Jaya Normina R.
Year and Section: BSN3
Group: 1-B
NURSING CARE PLAN
OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
Goal: Independent:
- Patient states relief 1. Check on the usual pattern of 1. It is very crucial to carefully know Goal met. Patient
from discomfort of elimination, including frequency and what is “normal” for each patient. verbalized relief from
constipation consistency of stool. The normal frequency of stool discomfort of
passage ranges from twice daily to constipation.
once every third or fourth day. Dry
and hard feces are common
Short Term Goal characteristics of constipation.
After 4 hours of nursing
intervention;
2. There is a big factor when
- Patient identifies 2. Take account of a possible laxative patient becomes dependent on
measures that prevent and enema use, type, and laxatives and enemas. Abuse of
or treat constipation. frequency.Check out usual dietary laxatives and enemas causes the
- Patient or caregiver habits, eating habits, eating schedule, muscles and nerves of the colon to
verbalizes measures and liquid intake. function inadequately in producing
that will prevent an urge to defecate. In the long
recurrence of run, the colon becomes atonic,
constipation. distended, and does not respond
normally to the presence of stool.
Long Term Goal Irregular mealtime, type of food,
After 8 hours of nursing and interruption of usual schedule
intervention; can lead to constipation.
- Patient maintains
passage of soft, formed 3. Sufficient fluid is needed to keep
stool at a frequency 3. Encourage the patient to take in the fecal mass soft. But take note
perceived as “normal” fluid 2000 to 3000 mL/day, if not of some patients or older patients
by the patient. contraindicated medically. having cardiovascular limitations
requiring less fluid intake.

4. Fiber adds bulk to the stool and

makes defecation easier because it
4. Assist patient to take at least 20 g of
dietary fiber (e.g., raw fruits, fresh
vegetable, whole grains) per day.
5. Urge patient for some physical
activity and exercise. Consider
isometric abdominal and gluteal
exercises.
Dependent:
passes through the intestine
essentially unchanged.
5. Movement promotes peristalsis.
Abdominal exercises strengthen
abdominal muscles that facilitate
defecation.
1. The use of laxatives or enemas is
indicated for short-term
management of constipation.

1. Administer pharmacological agent

as ordered.

1. These steps lead to establishing

Collaboration:
regular bowel habits.
1. Explain to the caregiver the
importance of the following:
-A balanced diet
-Sufficient fluid intake
-A regular period for elimination and
an adequate time for defection