SSESSMENT

DIAGNOSIS

PLANNING

Subjective:
Medyo hirap
akong dumumi. as
stated by client

Constipation
r/t decreased
motility of GI tract

After 4 of
nursing care, the
client will
demonstrate
lifestyle changes
to help establish
normal bowel
function

Objective:
Age: 68 y/o
(+) no BM x 2 days
(+) hard stool
(+) straining
(+) flatulence
(+) Abd distention

ASSESSMENT

AEB:
Clients statement,
older age, no bowel
movement for 2
days, hard formed
stool, straining,
flatulence, and
abdominal
distention

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION
After 4 of nursing
care, the client
demonstrated
lifestyle changes
to help establish
normal bowel
function
AEB:
(+) semi-formed
stool
() straining
() flatulence
() Abd distention

Instructed to eat
all the fruits and
vegetables served
at mealtime

To improve
consistency
of stool

Encouraged
adequate fluid
intake, warm
drinks if available

To promote
passage of
soft stool

Encouraged to
exercise daily
(e.g. walking),
as tolerated

To stimulate
contractions of
the intestines

Advised to wash
with warm water
after stools

For soothing
effect of rectal
area

Provided a calm,
relaxing
environment

To reduce stress
affecting normal
bowel activity

Suggested to
have a routine
schedule time for
defecation

So client can
respond to urge

INTERVENTIONS

DANQUE, MARILEE B.
RATIONALE
EVALUATION

Subjective:
Makikiraan po,
di ko po kayo
masyado makita.
as stated by client
Objective:
Age: 74 y/o
(+) blurry vision
(+) unsteady gait
(+) poor lighting
(+) lack of grab
bars in the
bathroom

ASSESSMENT

Risk for Injury

AEB:
Clients statement,
older age, blurry
vision, unsteady
gait, poor room
lighting, and lack of
grab bars in the
bathroom

DIAGNOSIS

After 2 of
nursing care, the
client will be free
of possible injury
in the ward

PLANNING
After 2 of

Evaluated muscle
strength, gross
and fine motor
coordination

To identify
possibility
of falls

Evaluated mood,
personality styles,
and stress
management

To determine
factors that
may result in
carelessness

Checked stability
of bed and
arranged personal
items at bedside

To increase
confidence in
self-care

Ensured pathway
to bathroom is
unobstructed

To aid in
maintaining
balance

Reoriented the
client to the
physical
environment

To enhance
familiarity and
coping abilities

Encouraged to
request
assistance when
needed

To help provide
individual wellbeing

INTERVENTIONS

After 2 of nursing
care, the client
was free of
possible injury
in the ward

DANQUE, MARILEE B.
RATIONALE
EVALUATION
After 2 of nursing

Subjective:
Wala naman ibang
magawa dito. as
stated by client
Objective:
Age: 65 y/o
(+) monotonous
tone
(+) disinterest
(+) lack of energy
(+) restlessness

Deficient
Diversional
Activity r/t
environmental
lack of leisure
or recreational
means
AEB:
Report of boredom,
monotonous tone,
disinterest in
surrounding, lack
of energy, and
restlessness

nursing care, the

client will display
appropriate
coping actions
and engage in
satisfying
activities within
personal limits

Acknowledged
reality of present
situation and
feelings of the
client

To establish
therapeutic
relationship and
support hopeful
emotions

Evaluated
attention span,
physical
limitations and
tolerance, and
safety needs

Illness, disability,
or depression
interferes with
desire for activity

To maximize
participation and
promote sense
of personal
fulfillment

To promote
psychosocial
and involvement
in natural
surroundings

To provide
positive sensory
stimulation

Identified with
client ways to
make ADLs
enjoyable (e.g.
singing while
bathing)
Recommended
socialization and
hobbies, such as
bird watching or
gardening
Encouraged
change of scenery
where possible

care, the client

displayed
appropriate coping
actions and
engaged in
satisfying activities
within personal
limits
AEB:
(+) cheerful tone
(+) attentive
(+) liveliness
(+) calm and
relaxed

DANQUE, MARILEE B.