NURSING CARE PLAN

NURSE Masakit yung

STATION tiyan ko!

ASSESSMENT
 OBJECTIVE:
• RLQ: Diminished
NURSE bowel sounds
• Constipated
STATION
SUBJECTIVE: • Bloated
“Masakit yung tiyan • Restlessness
ko!” as verbalized by • Pain in left lower
the patient. abdomen
• Pain scale: 5/10
• Vital Signs:
-BP: 132/80 mmHg
-PR:92 bpm
-Temp.: 37.5℃

ASSESSMENT
DIAGNOSIS:
Acute Pain related to Inflammation of
Diverticula as evidenced by
Verbalization of in Left Lower
Quadrant, Pain Scale of 5/10, and
Restlessness
PLANNING:
Within 1hr. of nursing interventions,
the patient will express relief of
painful symptoms and verbalize a
decrease in severity of pain.
INTERVENTIONS

MONITOR VITAL
SIGNS

RATIONALE:
Alterations from normal maybe
signs of infection.
INTERVENTIONS

ELEVATE THE HEAD OF THE BED AND

POSITION THE PATIENT IN SEMI
FOWLER’S.

RATIONALE:
To increase oxygen level by
allowing optimal lung expansion.
INTERVENTIONS

PLACE THE PATIENT IN COMPLETE

BED REST DURING SEVERE EPISODES
OF PAIN.

RATIONALE:
To reduce gastrointestinal
stimulations thereby decreasing GI
activity.
INTERVENTIONS

PERFORM NON-PHARMACOLOGICAL
RELIEF METHODS: TECHNIQUES SUCH
AS
DEEP BREATHING GUIDED PROVISION OF
EXERCISES IMAGERY DESTRUCTION SUCH AS TV
AND RADIO

RATIONALE:
To provide optimal comfort to the
patient.
INTERVENTIONS

ADMINISTER PRESCRIBED PAIN

MEDICATIONS

RATIONALE:
To alleviate pain
INTERVENTIONS

ADMINISTER PRESCRIBED PAIN

MEDICATIONS

RATIONALE:
To alleviate pain
EVALUATION
RE PLAN
 NURSE Hirap akong
STATION dumumi

ASSESSMENT
 OBJECTIVE:
• Constipation
NURSE alternating with
diarrhea
STATION
SUBJECTIVE: • Bloated
“Hirap po akong • RLQ: Diminished
dumumi” as bowel sounds
verbalized by the • Stool: Having
difficulty moving
patient.
bowel but has bouts
frequent soft stools
• Vital signs:
-BP: 132/80 mmHg
-PR:92 bpm
-Temp.: 37.5℃

ASSESSMENT
DIAGNOSIS:
Constipation related to Change in
Normal Bowel Habits as evidenced by
Bloating of the Abdomen
PLANNING:
Within 8 hours of nursing
intervention, the client will establish
or return to normal patterns of bowel
functioning.
INTERVENTIONS

DETERMINE STOOL COLOR, CONSISTENCY,

FREQUENCY AND AMOUNT.

RATIONALE:
Assists in identifying causative or contributing
factors and appropriate interventions
INTERVENTIONS

AUSCULTATE BOWEL SOUNDS

RATIONALE:
Bowels sounds are generally
decreased in constipation.
INTERVENTIONS

ENCOURAGE INCREASED FLUID INTAKE

OF 2500 – 3000 ML/DAY WITHIN CARDIAC
TOLERANCE.

RATIONALE:
Sufficient fluid intake is necessary for the bowel to absorb
sufficient
amounts of liquid to promote proper stool consistency.
INTERVENTIONS

RECOMMEND AVOIDING GAS-FORMING FOODS

SUCH AS NUTS, PEAS AND SPICY FOODS

RATIONALE:
Decrease gastric distress and
abdominal distension.
INTERVENTIONS

INSTRUCT CLIENT ON A HIGH-FIBER

DIET, AS APPROPRIATE.

RATIONALE:
Fiber absorbs water, which adds bulk and
softness to the stool and speeds up passage
through the intestines.
functioning.

EVALUATION