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NCP

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Cues/ Clues Nursing Diagnosis Goal Intervention Rationale Evaluation

Subjective Data: Alteration in bowel Short Term Encourage the Sufficient fluid is Short Term
 “Matigas yung elimination related to After 15 minutes of patient to take in needed to keep the
dumi ko tapos metabolic disorder nursing interventions, fluid 2 to 3 L/day, if fecal mass soft. But  Patient was
nakakadumi (hypothyroidism).  Patient not contraindicated take note of some able to
lang ako ng identifies medically. patients or older identify
dalawang measures patients having measures to
beses sa isang that prevent cardiovascular alleviate
linggo” or treat limitations requiring constipation
constipation. less fluid intake.
Objective Data:
 Decreased Long Term
bowels sounds After 2 days of Long Term
nursing interventions, Encourage patient to Fiber adds bulk to
 Palpable
 Patient eat food rich in fiber the stool and makes  Patient has
impaction
such as raw fruits, defecation easier
 Known to have maintains well-formed
fresh vegetables, and because it passes
hypothyroidis passage of stool at a
whole grain. through the intestine
m since 2015 soft, formed regular
essentially
stool at a unchanged. frequency.
frequency
perceived as
“normal” by
the patient. Promote physical Movement promotes
activity and exercise. peristalsis.
Consider isometric Abdominal exercises
abdominal and strengthen
gluteal exercises. abdominal muscles
that facilitate
defecation.
Cues/ Clues Nursing Diagnosis Goal Intervention Rationale Evaluation
Subjective Data: Acute pain related Short Term Maintain semi- Reduces abdominal After 20 minutes of
 “Masakit ang to inflammation of After 20 minutes of fowler’s position distension nursing interventions,
bandang tissues. nursing interventions,  Patient was
ibaba ng  The patient amenable to
tiyan ko sa will relaxation
may kanan ” demonstrate Provide comfort Promotes relaxation techniques
use of measures like deep and may enhance and comfort
Objective Data: relaxation breathing and patient’s coping measures
 Facial mask skills and diversional exercises. abilities by
of pain upon methods to refocusing attention
movement promote
 Positive comfort.
guarding Administer Aids in pain relief
behavior analgesics as ordered. and promotes healing
 Positive
rebound
tenderness
 Positive
Rovsing’s
sign
 Positive
psoas sign
 Positive
obturator
sign
 VS taken as
follows:
T: 38C
PR: 80bpm
RR: 18 bpm
BP: 110/70

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