Patient’s Name: Mr.

Boy1 Age: 49 Chief Complaint: Diarrhea 3 days PTA Room: 712-A

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
S: Diarrhea related At the end of the Assess >To have a Expected
“Ilang araw na to presence of shift, the patient contributing baseline data outcome:
akong infectious will report that factors Goal met.
nagdudumi, parasites as frequency of >To determine With distended
nakapito na nga evidenced by stools is reduced Monitor patient fluid volume abdomen
ako ngayong fecalysis of for signs of status and Without
umaga” as positive E. dehydration provide early complaint of
verbalized by the histolytica interventions abdominal pain
patient bacteria With hypoactive
>To have a bowel sounds
O: Note frequency, baseline data With 3 times BM
 With character and
distended volume of stools
abdomen >To determine if
 With Evaluate the diet the diet is
complaint of the patient appropriate for
of patient’s
abdominal condition
pain Review patient’s
 With laboratory results >To monitor for
hyperactiv especially presence of
e bowel fecalysis bacteria
sounds
 With 7 Monitor patient’s
times BM bowel sounds >To determine
in 8 hours; the peristalsis of
watery, the client
yellowish Encourage
in color, patient to >To prevent
scanty in increase fluid dehydration
amount intake
>To prevent
Emphasize the diarrhea
importance of
proper food
handling
>To prevent
Emphasize the diarrhea
importance of
proper boiling of
drinking water

Instruct patient >To decrease

on prescribed frequency of
proper diet such stools
as apple and
banana

Instructed to limit >To decrease

caffeine and high frequency of
fiber foods stools

Encourage
patient to rest >To regain
energy and
decrease
metabolic
Administer anti- demands of the
diarrheal drugs body
as ordered
>To decrease
frequency of
stools
Patient’s Name: Mr. Girl1 Age: 23 Diagnosis: Post CS Room: 703-B

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
S: Risk for Within the shift, Assess Goal met.
“hindi pa ako constipation the patient will contributing With hypoactive
nakakautot at related to gain usual factors > To have a bowel sounds
nakakadumi decreased pattern of bowel baseline data Positive flatus
dalawang araw peristaltic functioning as Monitor patient’s Negative BM
na simula nang movement evidenced by bowel sounds
manganak ako” secondary to positive flatus or
previous surgical positive BM Evaluate the
O: operation patient’s dietary > To provide
 With dry and fluid intake appropriate
and intact actions
dressing Review use of
on lower medications
mid
abdominal Emphasize the >To promote
area importance and activity and
 With encourage the increase
hypoactive patient on early peristalsis
bowel ambulation
sounds
 Negative Encourage
flatus patient to eat
 Negative high fiber foods
BM such as green
 leafy vegetables
>To promote soft
Encourage stool and
patient to stimulate bowel
increase fluid activity
intake

Administer
medications or
laxatives as
ordered

NURSING CARE PLAN

Windsor R. Salvosa

BSN IV – A – Group 19