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    Manguiat, Ncma 111 Romeo

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    Ciara Manguiat
    The patient was experiencing acute pain and constipation due to perirectal inflammation. The short term goals were to reduce the patient's pain level and return normal bowel movements through interventions like pain medication, relaxation techniques, and increased fluid intake. The long term goals were for the patient to independently manage their pain and maintain normal elimination through self-care behaviors like abdominal massage and a diet high in fiber.

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    Manguiat, Ncma 111 Romeo

    Uploaded by

    Ciara Manguiat
    131 views4 pages
    The patient was experiencing acute pain and constipation due to perirectal inflammation. The short term goals were to reduce the patient's pain level and return normal bowel movements through interventions like pain medication, relaxation techniques, and increased fluid intake. The long term goals were for the patient to independently manage their pain and maintain normal elimination through self-care behaviors like abdominal massage and a diet high in fiber.

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    MANGUIAT, NCMA 111 ROMEO

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    The patient was experiencing acute pain and constipation due to perirectal inflammation. The short term goals were to reduce the patient's pain level and return normal bowel movements through interventions like pain medication, relaxation techniques, and increased fluid intake. The long term goals were for the patient to independently manage their pain and maintain normal elimination through self-care behaviors like abdominal massage and a diet high in fiber.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    131 views4 pages

    Manguiat, Ncma 111 Romeo

    Uploaded by

    Ciara Manguiat
    The patient was experiencing acute pain and constipation due to perirectal inflammation. The short term goals were to reduce the patient's pain level and return normal bowel movements through interventions like pain medication, relaxation techniques, and increased fluid intake. The long term goals were for the patient to independently manage their pain and maintain normal elimination through self-care behaviors like abdominal massage and a diet high in fiber.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 4

    Manguiat, Ciara Loreal M.

    NCMA 111
    NURSING CARE PLAN
    BSN 1-Y2-5
    Romeo Garcia

    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


    Subjective Data: Short term: Independent: Independent: Short term:
    "Masakit at nahihirapan Acute pain related After a week of nursing Assess descriptive Pain is subjective in After 8 hours of nursing
    akong dumumi parang to inflammation of intervention, the patient will characteristics of pain at nature, and only the intervention, the patient was
    may nakalawit na balat the perirectal area be able to verbalize reduce of least every 2 hours, patient can fully describe able to verbalize a reduced
    dito sa puwet ko" (I've as evidenced by pain scale from 8/10 to 2/10. including location, quality it. Descriptions about the pain from 8/10 to 2/10.
    been having trouble / guarding behavior, and intensity on a scale of particulars of pain will
    pain pooping, it seems restlessness and The patient will state and 1-10, temporal factors, and help determine what goals The patient stated and carried
    that there's a skin facial mask of pain. carry out appropriate sources of relief, and pain are realistic for the out appropriate interventions
    protruding at my interventions for relief of tolerance. patient. for pain relief.
    anus) as verbalized by pain.
    the patient. Teach patient relaxation Promotes action and Long term:
    Long term: techniques such as guided effect of medication by After three weeks of nursing
    After three weeks of nursing imagery, deep breathing, providing decreased intervention the client:
    Objective Data: intervention the client will meditation, aromatherapy, stimuli. o Performed individual
    - Guarding able to: and progressive muscle relaxation techniques,
    behavior o Show individual relaxation. effective to achieve
    - Restlessness relaxation comfort.
    - Facial mask of techniques, effective Use the pain flow sheet. Knowing the client’s o Carried out
    pain to achieve comfort. level of perceived resocialization
    o Carry out characteristic of pain. behaviors and
    V/S taken as follows: resocialization activities.
    - Temp - 37.2°C behaviors and Check bowel elimination Immobility caused by o Stated importance of
    - PR - 95 activities; and at least once per shift. pain may decrease the self-care behavior or
    - RR – 20 o State importance of parasympathetic activities.
    - BP - 130/80 self-care behavior or stimulation to the bowel. o Demonstrated skin
    activities. Many analgesics have inspection technique.
    o Demonstrate skin constipation as a side
    inspection technique. effect. Goal was met.

    Dependent: Dependent:
    Reposition patient and use Patient needs to reduce
    pillows to splint or support muscle spasm and to
    painful areas, as redistribute pressure on
    appropriate specific body parts.
    Set up a behavior-oriented Behavioral–cognitive
    plan; for instance, set up a measures can help patient
    plan to follow the activity modify learned pain
    schedule. behaviors

    Administer analgesic pain Response to pain and pain


    medication as outlined in medication is unique to
    the plan. Reassess and each patient. When a
    document amount of pain patient requests more than
    relief within 30 minutes the plan allows, reiterate
    after administration. the terms of the plan in
    order not to overmedicate.

    Collaborative Collaborative
    Refer the patient pain to Collaboration promotes
    his physician. the best long-range plan
    for management of pain.
    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
    Subjective Data: Short term: Independent: Independent: Short term:
    "Masakit at Risk for After 16 hours of nursing Measure and total intake Allows monitoring of After 16 hours of nursing
    nahihirapan akong Constipation as interventions the patient will be and output every shift. adequate fluid intake to interventions the patient;
    dumumi parang may manifested by the able to: increase water content of o Returned his usual
    nakalawit na balat accumulation of o Return his usual bowel feces. bowel elimination.
    dito sa pwet ko" (I've hard defecation as elimination o Reported easy and
    been having trouble / evidenced by o Report easy and Emphasize importance of A timely response to the complete
    pain pooping, it guarding behavior, complete evacuation of responding to urge to urge to defecate is necessary evacuation of
    seems that there's a restlessness and stools. defecate. to maintain normal stools.
    skin protruding at my facial mask of pain. o Report an increase of physiological functioning. o Reported an
    anus) as verbalized fluid and fiber intake. increase of fluid
    by the patient. and fiber intake.
    Long term: Teach patient to massage Massage may help stimulate
    After 2 days of nursing abdomen once per day and peristalsis and the urge to Long term:
    Objective Data: interventions the patient will be how to locate and gently defecate. After 2 days of nursing
    - Guarding able to: massage along the interventions the patient:
    behavior o Elimination pattern transverse and descending o Eliminated pattern
    - Restlessness within normal limits colon. within normal
    - Facial mask o Adopt personal habits limits
    of pain that maintain normal o Adopted personal
    elimination. Teach patient sensible use To avoid laxative habits that maintain
    V/S taken as follows: o Participate in of laxatives and enemas. dependency. Overuse of normal
    - Temp - development of bowel laxatives and enemas may elimination.
    37.2°C program. cause fluid and electrolyte o Participated in
    - PR - 95 loss and damage to development of
    - RR – 20 intestinal mucosa. bowel program.
    - BP - 130/80
    Goal was met.
    Encourage patient to use a To encourage normal
    bedside commode or walk position for evacuation.
    to toilet facilities.

    Encourage intake of high- To supply bulk for normal


    fiber foods. elimination and improve
    muscle tone. Unless
    contraindicated, encourage
    fluid intake of 6–8 glasses
    (1,420–1,900 ml) daily to
    maintain normal metabolic
    processes.
    Dependent: Dependent:
    Monitor and record Allows early detection of
    symptoms associated with additional problems.
    passage of bowel
    movement: Any rectal
    bleeding or fissures.

    Provide privacy for To promote physiological


    elimination. functioning.

    To establish a regular
    Plan and implement an elimination schedule; and
    individualized bowel exercise routine to promote
    regimen. abdominal and pelvic
    muscle tone.

    Administer stool softeners Collaborate with physician


    as doctors prescribed. regarding additional
    pharmacological strategies.

    Collaborative: Collaborative:
    Collaborate with the To provide basic resources
    dietician, regarding a high and information needed and
    fiber, high-roughage diet. promote holistic approach
    to treatment.

    Help patient understand diet To encourage compliance


    modification plan along with prescribed diet.
    with dietitian, if
    appropriate.

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