NURSING CARE PLAN 

PATIENT’S NAME: GARCIA, ANGEL B.

AGE: 23
PHYSICIAN: DR. FRENZYLANE
Case Study: A 23-year old female student is admitted due to strained and painful bowel movement. The
patient complains of nonproductive periods of defecation. On assessment the nurse notices that the
patient's abdomen is distended. V/S: Temperature: 37.1°C (98.78°F); Blood pressure: 130/75 mmHg;
Respiratory rate:14 brpm; Pulse rate: 73 bpm.

ASSESSMENT  DIAGNOSIS  PLANNING  IMPLEMENTATION  RATIONALE  EVALUATION

SUBJECTIVE: Constipation After 8 hours Independent After 12 hours

(S): “Hindi na related to little of nursing •Recommend high •Dietary of nursing
ako madalas fluid intake intervention fiber diet fiber results intervention
dumumi tulad and low-fiber the patient in bulky the patient
ng dati. Kapag diet as will return to stool that will return to a
dumudumi evidenced by a normal passes normal bowel
naman ako, the patient’s bowel through the function.
mahirap at infrequent, function. colon easier
medyo hard stool and and helps
masakit” distended prevent
(I don’t go to abdomen. straining.
the bathroom
as often as I •Encourage fluid •Enough
used to. But intake of 2000 to fluids
when I do, it is 3000ml/day promote a
difficult and softer stool
painful) as consistency.
verbalized by
the patient. •Commence stool •Assesses
chart type, shape,
OBJECTIVE: and color of
(O): Abdominal the stool
distension and may
pinpoint any
Dry, hard stool other
digestive
Painful problems.
defecation
•Auscultate bowel •Bowel
Hypoactive sounds sounds
bowel sounds indicate
intestinal
Grimacing face activity.
•V/S taken as Dependent •Promotes
follows: •Administer defecation
T: 37.1°C laxatives or stool in presence
(98.78°F) softeners as of
BP: 130/75 prescribed by the constipation.
mmHg physician.
RR: 14 brpm
PR: 73 bpm