NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME

Assessment Diagnosis Mutual Planning Interventions Actual Evaluation

(Goal attainable within the shift) (with Rationale & Source)
Subjective: Constipation related to insufficient Short Term Goal: PRIMARY INTERVENTIONS Patient reported that
Patient verbalized that she has dietary habits as evidenced by After 8 hours of nursing Promotive: she now understood
not eaten well for a week. She patient’s report that she has not interventions, the patient will be I: Review daily dietary regimen, noting if diet is the causes of her
also stated, ““maglisod ko ug eaten well for a week and able to: deficient in fiber. condition, importance
kalibang ug di na taga adlaw verbalization of “maglisod ko ug  Verbalize understanding of R: Inadequate dietary fiber (vegetable, fruits, and of a balanced diet, and
pareha sa-una.” kalibang ug di na taga adlaw etiology and appropriate whole grains) and highly processed foods contribute the appropriate
pareha sa-una.” interventions or solutions for to poor intestinal function. interventions that she
individual situation S: Doenges, M.E., Moorhouse M.F., & Murr, A.C. can do to alleviate her
 Understand the importance (2016). concern. Patient
Objective: Theoretical basis: of a balanced diet expressed that she
V/S: Constipation during pregnancy is I: Explain to the patient the importance of sufficient was able to establish a
T: 36.4 c/axilla PR: 68bpm due to the increase in Long Term Goal: fluid intake (eight glasses per day or 2000 to 3000 bowel pattern.
BP: 100/70mmHg RR: 15cpm progesterone hormones that relax After 32 hours of nursing mL/day)
24-Hour Diet Recall: the intestinal muscle causing food interventions, the patient will be R: Increased hydration promotes a softer fecal mass.
Breakfast - pandesal and milk and waste to move slower able to: S: Wayne, G. (2017).
Lunch - fried fish and rice through your system (APA, 2020).  Establish or regain normal
Dinner - a burger and fries Dietary fiber is an important pattern of bowel functioning Preventive:
component of soft, solid and  Demonstrate behaviors or I: Note energy and activity levels and exercise
sausage-shaped stool which is lifestyle changes to prevent pattern.
considered as normal. One of the recurrence of problem. R: Lack of physical activity or regular exercise is often
leading causes of constipation is a factor in constipation.
insufficient fiber intake in foods S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
and it may be more pronounced (2016).
with strict dieting and fasting.
Fiber cannot be absorbed by the SECONDARY INTERVENTIONS
human body so it remains in the Curative
gut where it absorbs water to I: Instruct in and encourage a personalized dietary
keep stool soft. This helps with program that involves adjustment of dietary fiber and
the easy passage of stool. When bulk in diet (e.g., fruits, vegetables, and whole grains)
there is minimal intake of food and fiber supplements (e.g., wheat bran, psyllium)
due to fasting or dieting then there R: to improve consistency of stool and increase transit
is not enough residual material to time through colon, if slow transit through colon is
form stool. Essentially the bowels causing symptoms.
are “empty”. The little food that is S:Doenges, M.E., Moorhouse M.F., & Murr, A.C.
being consumed may not (2016).
comprise sufficient bulk to form a
 soft but solid stool which can then I: Encourage the client to maintain an elimination
be pushed out. It also depends on diary, if appropriate
the type of food that is consumed, R: to facilitate management of long-term condition,
if any food at all is eaten (Chris, and reveal the most helpful interventions.
n.d.). S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(2016).

I: Promote adequate fluid intake, including water,

high-fiber fruit, and vegetable juices, fruit/vegetable
smoothies, popsicles. Suggest drinking warm,
stimulating fluids (e.g., decaffeinated coffee, hot
water, or tea)
R: to avoid dehydration, promote moist, soft feces,
and facilitate passage of stool.
S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(2016).

I: Identify specific actions to be taken if the problem

does not resolve (e.g., return to physician for
additional testing and interventions)
R: to promote timely intervention, thereby enhancing
the client’s independence.
S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(2016).

I: Urge patient for some physical activity and exercise.

R: Movement promotes peristalsis.
S: Wayne, G. (2017)

Bibliography:
American Pregnancy Association. (2020). Constipation in Pregnancy. Retrieved on November 19, 2020 from https://americanpregnancy.org/healthy-pregnancy/pregnancy-health-
wellness/constipation-during-pregnancy-964/
Chris. (n.d.) Constipation with Dieting and Fasting – Causes and Remedies . Retrieved on November 19, 2020 from https://www.healthhype.com/constipation-with-dieting-and-fasting-causes-and-
remedies.html
Doenges E.M., Moorhouse M.F., & Murr. A.C. (2016). Constipation. Nurses’ Pocket Guide pp.310-316. Philadelphia, PA: F.A. Davis Company
Wayne, G. (2017). Constipation. Retrieved on November 19, 2020 from https://nurseslabs.com/constipation/