Our Lady of Fatima University

SSESSMENTDIAGNOSISPLANNINGINTERVENTIONSRATIONALEEVALUATIONSubjective:Medyo hirap akong dumumi. as stated by clientObjective:Age: 68 y/o(+) no BM x 2 days(+) hard stool(+) straining(+) flatulence(+) Abd distentionConstipation r/t decreased motility of GI tractAEB:Clients statement, older age, no bowel movement for 2 days, hard formed stool, straining, flatulence, and abdominal distention After 4 of nursing care, the client will demonstrate lifestyle changes to help establish normal bowel functionInstructed to eat all the fruits and vegetables served at mealtimeEncouraged adequate fluid intake, warm drinks if availableEncouraged to exercise daily (e.g. walking), as toleratedAdvised to wash with warm water after stoolsProvided a calm, relaxing environmentSuggested to have a routine schedule time for defecationTo improve consistency of stoolTo promote passage of soft stoolTo stimulate contractions of the intestinesFor soothing effect of rectal areaTo reduce stress affecting normal bowel activitySo client can respond to urgeAfter 4 of nursing care, the client demonstrated lifestyle changes to help establish normal bowel functionAEB:(+) semi-formed stool() straining() flatulence() Abd distentionDANQUE, MARILEE B.ASSESSMENTDIAGNOSISPLANNINGINTERVENTIONSRATIONALEEVALUATIONSubjective:Makikiraan po, di ko po kayo masyado makita. as stated by clientObjective:Age: 74 y/o(+) blurry vision(+) unsteady gait(+) poor lighting(+) lack of grab bars in the bathroomRisk for InjuryAEB:Clients statement, older age, blurry vision, unsteady gait, poor room lighting, and lack of grab bars in the bathroomAfter 2 of nursing care, the client will be free of possible injury in the wardEvaluated muscle strength, gross and fine motor coordinationEvaluated mood, personality styles, and stress managementChecked stability of bed and arranged personal items at bedsideEnsured pathway to bathroom is unobstructedReoriented the client to the physical environmentEncouraged to request assistance when neededTo identify possibility of fallsTo determine factors that may result in carelessnessTo increase confidence in self-care To aid in maintaining balance To enhance familiarity and coping abilitiesTo help provide individual well-beingAfter 2 of nursing care, the client was free of possible injury in the wardDANQUE, MARILEE B.ASSESSMENTDIAGNOSISPLANNINGINTERVENTIONSRATIONALEEVALUATIONSubjective:Wala naman ibang magawa dito. as stated by clientObjective:Age: 65 y/o(+) monotonous tone(+) disinterest (+) lack of energy(+) restlessnessDeficient Diversional Activity r/t environmental lack of leisure or recreational means AEB:Report of boredom, monotonous tone, disinterest in surrounding, lack of energy, and restlessnessAfter 2 of nursing care, the client will display appropriate coping actions and engage in satisfying activities within personal limitsAcknowledged reality of present situation and feelings of the clientEvaluated attention span, physical limitations and tolerance, and safety needsIdentified with client ways to make ADLs enjoyable (e.g. singing while bathing)Recommended socialization and hobbies, such as bird watching or gardeningEncouraged change of scenery where possibleTo establish therapeutic relationship and support hopeful emotionsIllness, disability, or depression interferes with desire for activityTo maximize participation and promote sense of personal fulfillmentTo promote psychosocial and involvement in natural surroundings To provide positive sensory stimulationAfter 2 of nursing care, the client displayed appropriate coping actions and engaged in satisfying activities within personal limitsAEB:(+) cheerful tone(+) attentive(+) liveliness(+) calm and relaxed

DANQUE, MARILEE B.

GANNABAN, EFREN