Name: Patient OMR

Age & Gender: 18/F

Medical Diagnosis: Dyspepsia, UTI; ruled out Appendicitis
Nursing Diagnosis: Risk for constipation related to disordered digestion as evidenced by verbal report
Short Term goal: After 8 hours nursing intervention, patient will gain knowledge on how to restore bowel movement
and decrease the risk for constipation
Long Term goal: After the hospitalization stay, patient’s bowel movement is back to normal
Date Cues Nursing Scientific Nursing Intervention Rationale Evaluation
Problem Rationale

06/22/10 “Hindi pa ako Risk for Dyspepsia -Advised the patient to -This will help moisten GOAL
nakakadumi constipation (Indigestion) is a increase oral fluid the GI Tract and can be PARTIALLY
simula kahapon” disordered intake a stimulant.
MET.
as verbalized by digestion: usually
the patient. applied to pain or -Maintained on a full -This order removes the The patient
discomfort in the meal diet food restriction of the gained knowledge
-(-) vomiting lower chest or patient from NPO to full on how to restore
abdomen occurring meal diet. bowel movement
-(-) Abdominal after eating and and decrease the
pain sometimes -Encourage patient to -Nutritious food will help risk for
accompanied by restore nutritious diet the patient recover and
constipation
-(-) Bowel nausea and gain energy.
movement vomiting.
-Advised patient to -Exercise can regain
-weak in Constipation is a perform some physical control of muscles and if
appearance condition in which exercise concentrated to the
bowel evacuations abdomen, it can
PR = 55bpm occur infrequently, stimulate contractions of
or in which the the intestine thus
feces are hard and producing a bowel
small, or where movement.
passage of feces
causes difficulty or
pain.

Annotation:
Disonglo, Jorge Jr. B. The bantam
BSN 4-C, Grp. 9 Medical dictionary
5th edition