Joseph is a call center
representative with morning shifts. Because of his 9-5 work and being
workaholic, he usually forgot to take his personal needs like urinating, drinking
and even defecation. He is always an employee of the month and always gets a
lot of commissions however, he didn't notice something is going wrong with him
and if he doesn't act fast it may lead to complication. Below is a sample of
constipation nursing care plan of Joseph, a call center representative.
ASSESSMENT
Subjective:
"I’m having difficulty in defecation because of my dry stool," as verbalize by the patient.
Objectives:
I observed from the
patient that he has a distended abdomen and upon palpation, the patient has a
tender abdomen without palpable muscle resistance. Through percussion, I
detected dullness in the abdomen. (We consider a Joseph that he had a
distended abdomen when his belly is swelling, distended abdomen is usually
called swelling of the abdomen. While tender abdomen is when you palpate the
abdominal area and you feel that it is hard and had a mass.) His sample stool
is hard-dry.
The patient's vital
signs are taken and noted as follows: Body temperature is 37.2 degrees Celsius,
blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, pulse
rate is 82 beats per minute. Respiratory rate and pulse rate is normal while
the patient's body temperature is above normal. His/her blood pressure is categorized
as pre-hypertension.
DIAGNOSIS
Constipation related to
observed hard, formed stool as evidenced by distended abdomen and palpable
abdominal mass.
PLANNING
After 8 hours of nursing
intervention, the patient will regain normal pattern of bowel functioning.
INTERVENTION
- Review your Joseph's
dietary regimen and note if his diet is deficient in fiber. Fiber helps food to
move through your digestive tract more quickly for healthy elimination so
encourage Joseph to have a balanced diet that rich in fiber. Fiber-rich
foods are whole foods, fruits and vegetables.
- Ask Joseph about
his fluid intake and evaluate his hydration status. Encourage him to have
adequate fluid intake because this will promote his passage to stool. Tell
Joseph to drink at least 8 glasses of water every day.
- There are other
factors you should consider to Joseph such as activity level and
exercise, pain in defecation, and bowel obstructions. (Did you know that
sedentary lifestyle of Joseph may affect elimination patterns and activities
beyond his body’s limit reduce stimulation for contractions of intestines?)
Pain in defecation is sometimes caused by hemorrhoids; it is the swelling of
veins in the rectum and anus. Fecal impaction is one of the most causes of
bowel obstruction.
- Encourage
Joseph for treatment of underlying medical causes of constipation where
appropriate to improve organ function, including his bowel. Administer enemas
and/or digitally remove impacted stool and establish bowel program to include
glycerin suppositories and digital simulation, as appropriate, when long-term
or permanent bowel dysfunction is present.
EVALUATION
After 8 hours of nursing intervention, the patient regained the normal pattern of bowel functioning.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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