Nursing Care Plan

Nursing Care Plan
Name : Mrs. Ratna sari Patient’s health profile : she never complaint about her bowel before.
But, since her husband’s death she is alone, she
does not cook for herself. As a result, she has
developed irregular eating patterns and tends to
prepare soup-and-toast meals and She gets little
exercise too.
Age : 52 Years Old Sex : Female
Occupation : housewife
Status : widow Religion : Muslim
Date of : 20- 11-2019
Admission
complaints : klient said that her bowel movement Impression : Abdominal/ gastrointestinal
about every 3 to 4 days and her stools are
hard and painful to excrete
Assessment Nursing diagnosis Objective Orders Rationale Implementation Evaluation

Subjective : Constipation After 8 hours a. Identify factors a. Assessing causative 1. Identifying factors Outcome not met.
She states she relate to low fiber nursing (e.g., medications, factors is an essential (e.g., medications, bed Mrs. Sari has kept a food
has a bowel diet and inactivity After nursing bed rest, diet) first step in teaching rest, diet) that may diary and is able to
movement (as evidenced by intervention that may cause or and planning for cause or contribute to identify the need for
about every 3 to infrequent, hard expected patient contribute to improved bowel constipation more fluid and fiber but
4 days and her stools; painful will has a food constipation elimination. has not consistently
stools are hard defecation; diary and will able 2. Increasing intake of included fiber in her diet.
and painful to abdominal to identify the need b. Encourage b. Sufficient fluid intake fluids She has been in elderly
excrete distention) for more fluid and increased fluid is necessary for the posyandu but is not
fiber and intake, unless bowel to absorb 3. Reviewing a history of available every month.
Objective : consistently Contraindicated sufficient amounts of medications use
 bowel sounds included fiber in liquid to promote
are not very her diet. proper stool 4. Teaching mrs. Sari how
active, She’ll be diligent in consistency. to keeping a food diary
 abdomen elderly Posyandu
slightly program each c. Review a history c. Constipation is a 5. Instructing mrs. Sari on
distended month. of medication use common side effect of a high fiber diet
for
 Temperature: gastrointestinal many drugs including 6. Instructing to stay
36.2°C (97.2°F) side effects narcotics and antacids. balancing of diet,
 Pulse: 82 BPM exercise and fluid
 Respirations: d. Teach Mrs. Sari d. An appraisal of food intake
20/minute how to keep a intake will help 7. Encourages verbalizing
 Blood food diary. identify if Mrs. Sari is feelings about exercise
pressure: eating a well-balanced or the need to exercise
128/74 mm Hg diet and consuming
adequate amounts of 8. determine the
fluid and fiber. motivation for starting
Excessive meat or / continuing an
refined food intake exercise program
will produce small,
hard stools. 9. gave an explanation to
Ms. Sari about the
e. Instruct Mrs. Sari e. Fiber absorbs water, health benefits and
on a high-fiber which adds bulk and physiological effects of
diet, as softness to the stool exercise.
appropriate and speeds up
passage through the 10. instructing her about
intestines. the type of exercise
f. Instruct her on that is suitable for his
the relationship f. Fiber without health level, follow
of diet, exercise, adequate fluid can the elderly Posyandu
and fluid intake to aggravate, not program
constipation and facilitate, bowel
impaction function.
g. Encourage
verbalization of g. Perceptions of the
feelings about need for exercise may
exercise or need be influenced by
for exercise misconceptions,
cultural and social
beliefs, fears, or age.
h. Determine her
motivation to h. Individuals who have
been successful in an
begin/continue an exercise program can
exercise program assist Mrs. Sari by
providing incentive
and enhancing
motivation. For
example, a walking
partner may be
beneficial.
i. Inform Mrs. Sari
about the health i. Activity influences
benefits and bowel elimination by
physiologic improving muscle tone
effects of and stimulating
exercise. peristalsis.
j. Instruct her about

appropriate types j. Any individual
of exercise for her beginning an exercise
level of health, program should
and follow the consult a primary care
elderly Posyandu provider primarily for
Program a cardiac evaluation.
Mrs. Sari’s age and
lack of activity should
be considered in
planning the level of
activity.
English task
Nursing care plan
By:
Dewi purnamasari
Nim. 18.01.084

Nursing Care Plan

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Nursing Care Plan

Assessment Nursing diagnosis Objective Orders Rationale Implementation Evaluation

j. Instruct her about

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