Cezaldo, Eva Marielle R.

2 BSN

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Constipation related Short Term Goal: Independent After 2-3 days of
G1T0P0A0L0 to first time After 4 hours of - Inform the patient - To improve the nursing
Age: 30 years old pregnancy as nursing that constipation is a understanding of the interventions:
evidenced by hard interventions, the common concern patient about
“Simula nung stools and difficulty patient will be able among pregnant constipation. - The patient
nagbuntis ako, with bowel to: women. reported that she
medyo matigas yung movements now understood the
dumi ko”, as - Verbalize etiology and
verbalized by the understanding of the - Identify the color, - It will assist in appropriate
patient. etiology and consistency, identifying the interventions for
appropriate frequency, and causative factors that constipation.
When she was asked interventions for her amount of stool of may contribute to
if she does have situation. the patient. constipation. - The bowel pattern
difficulty with bowel and feces character
movements, she said Long Term Goals: both changed
“Oo”. After 2-3 days of -Determine usual - Inadequate dietary significantly.
nursing dietary and fluid intake of the patient
interventions, the intake of the patient. may cause - Patient verbalized
patient will be able constipation and the relief from
to: fluid intake can discomfort and
evaluate patient’s stated measures that
- Regain or establish hydration status. prevents
normal pattern of constipation.
bowel movement.
- Encourage the - To keep the fecal - Goal Met
- Maintains passage patient to consume material soft,
of soft, formed stool 2000 to 3000 mL of adequate and
at a frequency fluid per day if it is sufficient fluid is
perceived as not medically required.
“normal”. contraindicated.

- States relief from - To enhance stool

discomfort of - Instruct and consistency and
constipation. encourage the assist passage
patient to take a through the colon.
- Identifies methods fiber-rich diet, as well
that prevent or treat as fiber supplements.
constipation.
- Movement
- Encourage physical promotes peristalsis.
activity and exercise
within the limits of
the patient’s own
capabilities.
- For the patient to
- Provide comfort to feel comfortable and
the patient. safe.

Dependent - To treat the patient

- Administer if she does have any
medications as underlying
prescribed by the conditions.
physician.