NURSING CARE PLAN ASSESSMENT hindi na ko madalas dumumi at sumasakit yong tiyan ko as verbalized by the patient.

. Patient rated pain as 4/10 in a scale of 0-10 and 10 is the highest scale felt. Objective distended abdomen (+) borborygmi sounds Oral fluid intake (100-150ml) a day V/S taken as follows: T: P: R: BP: Constipation EXPLANATION OF THE PROBLEM OBJECTIVE After 8 hours of nursing interventions the patient will establish or return to normal patterns of bowel functioning INTERVENTIONS Independent Determine stool color, consistency, frequency, and amount. RATIONALE Assist in identifying causative or contributing factors and appropriate interventions. Bowel sounds are generally decreased in constipation. Assist in improving stool consistency. Decrease gastric distress and abdominal distention. Prevents skin excoriation and breakdown. EVALUATION

Auscultate bowel sounds Encourage fluid intake of 25003000 ml/day within cardiac tolerance Recommend avoiding gas forming foods Assist in perinial skin condition frequently, noting changes or beginning breakdown.

related to decreased dietary intake.

Discuss use of stool softeners, mild stimulants, bulk forming laxatives or enemas as indicated. Monitor effectiveness. Encourage to eat high fiber rich foods. Collaborative: Consult with dietitian to provide well balanced diet high in fiber and bulk.

Facilitates defecation when constipation is present.

To enhance easy defecation. Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which act as stimulant to defecation.

NURSING CARE PLAN ASSESSMENT hindi ko na magawang maligo at mag ayos pa ng katawan dahil sa tinatamad ako as verbalized by the patient. Objective: Discomfort Unpleasant odor Unfixed hair Dry skin presence of dandruffs. Self-care deficit related to decreased motivation and in performing good hygiene. EXPLANATION OF THE PROBLEM OBJECTIVE After 1 hour of nursing interventions, the patient will perform good hygiene and he will cooperate in the procedure of bathing and proper grooming. INTERVENTIONS Establish rapport on the client. Monitor the vital signs. Provide health teaching on the client regarding the proper way of effective oral hygiene. Explain the procedure of proper bathing and hair brushing on the patient. Guide and support the patient and let him perform the procedure. Encourage him to take a bath everyday and be responsible on his RATIONALE To establish trust and cooperation on the client. To obtain the baseline data. To provide adequate knowledge on the client. To provide correct pattern of performing the procedure. To avoid accident and for the patient to practice the procedure. To inform the patient of his responsibility as an individual. EVALUATION

appearance. Inform the relatives to help the patient on doing his duty everyday regarding his proper hygiene.

To have cooperation and guidance coming from the relatives.

NURSING CARE PLAN ASSESSMENT EXPLANATION OF THE PROBLEM OBJECTIVE INTERVENTIONS RATIONALE EVALUATION