NURS240L Nursing Process Assignment Student Name___________Brian Rose_________

Nursing Care Plan for Priority Nursing Diagnosis Rm#______J.P._____ _____

1 Assessment (Your findings from prep day and days
1&2 that relate to the problem. Include dates collected)
Subjective
(Client states r/t problem)
Client states “I haven’t
had a BM since the my
C/S”
Client states “the time
between going to the
bathroom is more than
normal”
Objective
(Data)
Client is 2 days P.O.
Taking opiate analgesics
(Oxycodone) every 4hrs
Client is apprehensive
about ambulation and
slow in general
movements even while at
bedrest. Possibly related
to fear of pain
Intake was 480ml during
my shift.
No BM to date while in
postpartum.
Client on REG. diet.
Eating 100% of breakfast
4 Planned Interventions (Nursing care
that will assist to resolve problem. Date when done.)
• Encourage regular intake of food emphasizing foods
high in fiber i.e. fruits such as raisins, apples and
bananas, grains and cereals, leafy greens
• Assess current activity level and tolerance. Include
pain level every two hours and administer analgesics
per physician’s orders.
• Evaluate current medication usage that may
contribute to constipation. Educate client about side
effect of use.
• Evaluate fear of pain
• Encourage daily fluid intake of 2000 to 3000 ml/day,
if not contraindicated medically.
• Encourage ambulation with assist as tolerated.
• Educate client about a general pattern of constipation
following pregnancy.
• Suggest the following measures to minimize rectal
discomfort: use of Tucks pads to relieve
hemorrhoidal and perineal pain. Use of ice packs to
relive pain associated with episiotomy
5 Rationales
(Why intervention is appropriate, what it accomplishes)
• The bowels tends to be sluggish after birth because
of the lingering affects of progesterone, decreased
abdominal muscle tone, and bowel evacuation
associated with labor and birth process
• Change in mealtime, type of food, disruption of
usual schedule, and anxiety can lead to constipation.
• Prolonged bed rest, lack of exercise, and inactivity
contribute to constipation.
• Opioid analgesics and iron supplements taken
pre/postpartum can contribute to constipation
• Women who have had episiotomy, lacerations or
hemorrhoids may tend to delay elimination for fear
of possible pain. Delaying bowel movements may
increase constipation and subsequently cause more
pain
• Dehydration compounds and contributes to
constipation.
• Ambulation strengthen abdominal muscles that
facilitate defecation.
• Pain relief may reduce anxiety which is associated
with such conditions and promote desire for
elimination

2 Nursing Diagnosis
(Problem identified in assessment)
Impaction; obstipation r/t pregnancy d/t decreased
mobility and use of opioid analgesics. Reference w/page #s: Nursing Care Plan pg 46-48 Old’s
pg 1045
3 Outcomes (Specific to client & Nsg Dx, realistic, measurable, and time limited with baseline 6 Evaluation (Were outcomes accomplished? If not, why)
data in Assessment) Date & Time:
Client will verbalize at least 3 means of promoting peristalsis by end of shift On 4/16/10 at 0830, Client met outcome by stating “drinking plenty of water,
4/16/10. eating foods high in fiber, and getting out of bed and moving around”
Criteria for Nursing Process Assignment
1. Assessment
1. Is subjective data in the client’s or significant other’s own words or accurately paraphrased?
2. Is objective data in the form of specific measurements from student’s assessment (ie, resp rate, breath
sounds, wound measurement, etc) and diagnostic information from the chart? Are dates included? Subjective
3. Does data relate ONLY to the problem identified in nursing diagnosis?
4. Does data adequately support the nursing diagnosis or is additional data needed? Objective
2. Nursing Diagnosis
1. Does the nursing diagnosis accurately describe the problem or risk identified in the assessment? Nursing Diagnosis
2. Is the nursing diagnosis NANDA?
3. Does the “related to” section describe the etiology (cause) of the problem (in physiological terms)?
4. If “high risk for” diagnosis, are the risk factors listed instead of “related to” section?
3. Outcomes (Use action verbs only. You must be able to use outcomes in the evaluation step to measure
client’s response to nursing interventions.)
1. Are outcomes specific, realistic, measurable and have an appropriate and realistic time limit? Outcomes
2. Are there baseline measurements for all outcomes in the assessment?
3. Do outcomes demonstrate improvement or at least no worsening of the problems?
4. Do outcomes reflect changes expected as the result of nursing interventions?
4. Interventions: List references (Text & page#)
1. Do nursing interventions address the identified problem?
2. Do interventions help resolve the problem? Interventions
3. Do interventions best accomplish the outcomes?
4. Are interventions individualized to client (“O2 as ordered” would not be individualized but “O2 at 2L
per NC” would be.)
5. Are interventions specific enough? (“Increased activity” would not be specific but “Walk length of
hallway qid” would be.)
6. Are references listed?
7. Have interventions been done? Date when done added to intervention?
5. Rationales
1. Do rationales explain why the intervention is appropriate to resolve the problem? Rationales
2. Do rationales explain what the rationale accomplishes?
6. Evaluation (Determines effectiveness of plan of care and addresses outcomes.
1. Were outcomes evaluated by reassessment? Evaluation
2. Were specific findings reassessed and listed?
3. Did the outcome (change) occur? Were outcomes met? If not, why?