ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATIONS:“Nakakainom ako ng tubig hanggang limang baso sa isang araw. Madalas pa rin akong umihi, mga 5to 7 times, pero ang pagdumi ko ay hindi na araw araw.” as verbalized.

O> Dry lips>Bowel sounds : RUQ; 4,LUQ,-4 RLQ,-3 , LLQ-4>pail nail beds and capillary refill of 2 secs>dry cracked heels>brown and well-formed stool>yellow urine

Risk for constipation related to decreased fluid intake

Insufficient intake of fluids within the day can cause decrease in frequency of defecation. It can be accompanied by difficult passage of stool, or excessively dry and hard stool.

Short-term goal:After 8 hours of nursing interventions, the client will be able to maintain usual pattern of bowel functioning.

Long-term goal:After 3 days of nursing interventions, the client will be able to demonstrate lifestyle changes to prevent the risk of constipation.

Objectives:After 8 hours of nursing interventions, the client will be able to : Verbalize

understanding of risk factors and appropriate interventions related to the situation.

Participate in the plan of care.

Independent:1. Assess the

condition of the patient.

2. Review medical and social history of the patient.

3. Instruct the client to increase fiber and bulk in the diet like fruits and vegetables.

4. Promote adequate fluid intake including water and high-fiber fruit juices.

5. Discuss the physiology in elimination and its risk factors.

6. Encourage activity and exercise according to the client’s tolerance level.

7. Encourage client to maintain elimination diary.

Dependent:1. Administer laxatives

and enema as prescribed by the doctor.

Collaborative:1. Include the family in the plan of care.

1.To provide baseline information.

2. To identify risk and contributing factors.

3. Increased fiber will improve the consistency of stool and facilitate passage through the colon.

4. Adequate fluids will promote soft stool and stimulate bowel activity.

5. To provide the client understanding about constipation and his condition.

6. To stimulate contractions of the intestines.

7. To include patient in the care and to help monitor bowel pattern.

1. Laxatives and enema will help in bowel elimination with ease.

1. Providing family in the health care will promote

Short-term goal:After 8 hours of nursing interventions, the client defecated once with brown well-formed stool with ease.

Long-term goal:After 3 days of nursing interventions, the client was able to participate in the plan of care and demonstrate lifestyle changes that reduced the risk of constipation.