Island Home Health Care ‫ايالند هوم للرعاية الصحية المنزلية‬

NURSING CARE PLAN

PATIENT NAME: WARAQA BAKHEET AL RASHIDI
MRN: 000088 DATE: JANUARY 2021
MEDICAL DIAGNOSIS: ASCITES, MALIGNANT; DISTENDED ABDOMEN; BOWEL OBSTRUCTION; ELECTROLYTE IMBALANCE; ACIDOSIS; HTN; SPONTANEOUS BACTERIAL
PERITONITIS;CONSTIPATION

PROBLEM 1:
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S: N/A Constipation related to lack Patient will be able to pass -Monitored vital signs every 4 hours or Goal not met. Patient still
of inactivity and presence of stool daily without any as necessary including abdominal girth wasn’t able to pass stool even
O: -Infrequent passage
malignant pelvic mass. discomfort. and bowel sounds. after administering routine
of stool
- Administered routine laxatives daily. and PRN laxatives; she still
- passage of liquid fecal
- Administered PRN laxatives. has intermittent vomiting and
seepage
- Ensured patient received required abdominal distention was not
-intermittent vomiting
daily nutrition of Glucerna 40ml/hr and relieved.
of yellowish gastric
water flushing of 100ml every 4 hours
contents
through PEG with strict aspiration
approximately 30mL
precaution.
- abdominal distention
-Re- positioned patient on bed every 4
- tympanitic abdomen
hours.

IHHC/NRSG/FORM/0035-16 1
 Island Home Health Care ‫ايالند هوم للرعاية الصحية المنزلية‬

PROBLEM 2:
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S: N/A Ineffective breathing pattern Patient will demonstrate an -Monitored vital signs every 4 hours or Goal partially met. Patient’ s
related to decreased lung effective breathing pattern, as necessary including breathing pattern breathing pattern still
O: -Shallow breathing
expansion and inflammatory as evidenced by relaxed and lung sounds remained shallow; but there
- Repiration
process. breathing, normal rate and - Administered prescribed cough is no use of accessory
range from 20-
depth and absence of medicine and antibiotic. muscles during breathing; her
24 CPM
dyspnea. - Kept head of bed elevated at all times. respiration became normal at
- Presence of
-Re- positioned patient on bed every 4 19-20 CPM; coughing was
adventitious
hours; performed chest, back tapping relieved and secretions were
lung sounds
and suctioning of oral secretions during lessened.
- Ineffective
re- positioning or as necessary.
productive
.
cough with
copious
amount of
loose clear-
white oral
secretions

NURSE ON DUTY: SUSAN ANNE C. BUHAY, 29822

IHHC/NRSG/FORM/0035-16 2