CENTRO ESCOLAR UNIVERSITY

Manila*Makati*Malolos

NURSING CARE PLAN

Situation: Angela is a 22 year old Chinese transgender male to female person. She seems nervous and does not make eye
contact. English is not her first language. She does not live with her parents but there is consistent communication among
them. She is currently going through estrogen hormone therapy. She has a history of depression and drug use. Angela was
referred by a local CBO to your clinic to obtain an annual physical examination.

ASSESMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION

SHORT TERM: Independent Independent N.I. SHORT TERM:
UBJECTIVE DATA: ACTUAL  After 24 N.I. 1 Sedentary lifestyle such PARTIALLY MET
DIAGNOSIS: · hours of 1.Asses the as sitting all day, lack of  After the client
According to the client she patients
nursing exercise, prolonged bed receive the
have a history of Depression  The patient activity level
and Drug Use. experience intervention rest and inactivity intervention,
2. Classify
·
anxiety, she the client will contribute to she will bowel
 Document of current
seems constipation atleast two
OBJECTIVE DATA: nervous and the client’s medications
2. A lot of drugs can slow times a day
 The client is can’t eye food pattern; usage that
down peristalsis. LONG TERM:
currently using contact. do not guess may lead to MET
estrogen Opioids, antacids with
 Acquire constipation.  after receiving
hormone RISK DIAGNOSIS: client’s times 3.Feel the
calcium or aluminum
therapy. Risk for Anxiety the
of bowel. base, antidepressants,
Vague sense of need for intervention,
anticholinergics,
VITAL SIGNS: unease home privacy for the clients will
LONG TERM: antihypertensives,
generally elimination. defecates trice a
The client's undetermined or  After 2 Reference: general anesthetics,
 day or bowel
temperature unknown. weeks of https:// hypnotics, and iron and
nursing atleast 3 times a
is 37.8 ºc. nurseslabs.co calcium supplements can
intervention m/
week
 Cardiac rate cause constipation
the clients constipation/
 is 85 beats will: Dependent 3. Defecating is a private
per minute HEALTH  The patients N.I. thing. Most patients may
 Respiratory PROMOTION Bowel will be 1. Check on have a hard time having
rate is 20 /WELLNESS normal and the usual
DIAGNOSIS: a bowel movement away
breaths per defecates pattern of from the sense of privacy
 Readiness for
minute health trice a day.. elimination, in their home.
 Blood improvement including Reference:
pressure is as she have frequency https://nurseslabs.com/
120/80 consistent and constipation
communication
consistency
aming her
parents. of stool
. Dependent N.I.
2 Take 1 It is very crucial to
account of a carefully know what is
possible “normal” for each
laxative and patient. The normal
enema use, frequency of stool
type, and passage ranges from
frequency. twice daily to once every
.3.Check out third or fourth day. Dry
usual dietary and hard feces are
habits, eating common characteristics
habits, eating of
schedule, and constipation.
liquid intake 2.It is very crucial to
Rereference: carefully know what is
https:// “normal” for each
nurseslabs.co patient. The normal
m/ frequency of stool
constipation/
passage ranges from
Collaborative twice daily to once every
N.I. third or fourth day. Dry
1.. Evaluate and hard feces are
for fear of common characteristics
pain with of constipation.
defecation. 3.Irregular mealtime,
2. Consider type of food, and
the degree to interruption of usual
which the schedule can lead to
patient constipation.
responds to Reference:
the urge to https://nurseslabs.com/
defecate. constipation/
3. Know if
there is a
Collaborative N.I.
history of
1.Conditions such as
neurogenic
hemorrhoids, anal
diseases,
fissures, or other
Reference:
anorectal disorders that
https://
are painful can cause the
nurseslabs.co
m/ patient to ignore the
constipation/ urge to defecate, which
over time results in a
dilated rectum that no
longer responds to the
presence of stool.
2.Ignoring the urge to
defecate eventually leads
to chronic
constipation because the
rectum no longer senses
or responds to the
presence of stool. The
longer the stool stays in
the rectum, the drier and
harder it becomes. This
will make the stool
difficult to pass.
3.Neurogenic disorders
may decrease peristaltic
activity.
Reference:
https://nurseslabs.com/
constipation/