DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Nam Kyung Jin Date of Admission: February 9, 2024 Room: 405B
Age: 68 years old Sex: Male Civil Status: Not indicated Chief Complaint: Abdominal distention, bilateral pedal edema, shortness of
breath, loss of appetite
Attending Physician: Dr. Miranda

GOALS & NURSING

DATE/ CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
TIME DIAGNOSIS
Subjective: After 8 hours of 1. Administer PNSS 1L @ 1. By maintaining the February 9, 2024 @
February Nsg Dx: care, the patient will KVO rate patient's equilibrium and 3:00 PM
9, 2024 @ “Wala din akong be able to manifest hydration, this IV fluid
Constipation related
7:00 AM ganang kumain the following: supports the liver's function
to change in normal
dahil parati without stressing it. “GOAL MET”
bowel habits as
akong evidenced by a  The patient
naduduwal. will report After 8-hour span of
decrease in stool
Lugaw nalang frequency soft, formed 2. Encourage the patient to 2. Older clients who are care, the patient was
ang aking stool during increase fluid intake of 1.5 constipated should at able to manifest:
kinakain, kaso bowel to 2 L/day as tolerated. least drink up to two liters
nasa dalawa o movements of water daily unless  The patient
SCIENTIFIC at least once contraindicated. was able to
tatlong kutsara BASIS: a day. Adequate fluid intake verbalize
lang ang kaya
makes the stool softer understanding
kong maubos sa Constipation occurs and easier to pass
 The patient of the
isang araw. when your bowel throughout the large recommended
will be able to
Medyo lumiit movements intestine.
identify high-fiber diet
nga become less
actions to and fluid
pangangatawan frequent and stools
prevent intake to
ko kumpara become difficult to 3. Advised patients to take 3.Patients are
constipation promote
nung makalipas pass. It happens
in the future. the recommended dose of encouraged to increase optimal bowel
na linggo. Mula most often due to dietary fiber of at least 20 to their dietary fiber by function.
sa 60kgs na changes in diet or
 The patient 30 g daily. Encourage consuming whole grains,
routine, or due to
timbang ko will be able to intake of prune juice. bran, nuts, fruits, and  The patient
inadequate intake vegetables.
noong enumerate revealed an
of fiber. This
nakaraang behavior or improved state
happens because
linggo, ay nasa lifestyle of hydration
55kgs nalang your colon absorbs changes to 4. Assist the patient in doing 4. Walking and mild and a gradual
ako ngayon. too much water prevent physical activity and physical activity stimulate stimulation of
from your poop. constipation. exercise in which he can peristalsis that promotes bowel mobility.
Napagmasdan
This dries out your tolerate. defecation. Allowing
ko rin na hindi
poop, making it individuals to be  The patient
na araw-araw hard in consistency
ang aking physically active defecated
and difficult to push facilitates normal bowel within the
pagbabawas, out of your body. function, enhances shift.
aabutin pa ng
appetite, and improves
tatlong araw
the quality of life.
bago ako
makapag
bawas.” 5. Institute a toilet schedule 5. Defecation is
or bowel training as considered a conditioned
appropriate. reflex, which allows
Objective: individuals to defecate at
Temp: 37.5 c approximately the same
BP: 140/90 time every day, notably in
mmHg the morning or after
HR: 95 bpm meals when the
RR: 23 cpm gastrocolic reflex is most
O2 sat: 96% active in stimulating
Weight: from peristalsis, which makes
60 kgs to 55 the defecation process
easy.
Lab Values:
Albumin: 2.0
g/dL (H) 6. Administer and explain 6. Laxatives are
BUN: 36 the use of pharmacological recommended when
mg/dL (H) agents as ordered. nonpharmacological
Creatine: 1.4 measures such as
mg/dL (H) behavioral modification
and diet are ineffective in
REFERENCES: managing constipation.
Bsn, G. W., RN.
(2023a, October 12).
Constipation Nursing 7. Administer Lactulose 7. Helps with constipation
Care plan and (Duphalac) 30 cc OD at HS and reduces ammonia
Management.
Nurseslabs. as ordered. levels in the blood, which
https://nurseslabs.co can improve mental
m/constipation/#googl function in patients with
Laboratory liver cirrhosis.
e_vignette
Values:
Professional, C. C. M. 8. Monitor and record 8. Provides information
(n.d.). Constipation. intake and output. about fluid intake,
Cleveland Clinic. hydration, dietary needs,
https://my.clevelandcli and effectiveness of
nic.org/health/disease
s/4059-constipation therapy.

9. Emphasize the 9. Health teaching should

importance of lifestyle focus on the prevention
changes. of constipation rather
than medications. Patient
education should include
lifestyle changes such as
proper diet, adequate
hydration, regular
physical activities, and
exercise.

Name of Student: Irish T. Cacayan, SN.