Reymon Jan B.

Rodado ASSESSMENT DIAGNOSIS INFERENCE Uterine abnormalities and infection l estrogen production unopposed by progesterone l lead to endometrial hyperplasia l endometrium sloughs l abnormal uterine bleeding PLANNING After 4 hrs. Of nursing interventions, the patient will report fear and anxiety are reduced to a manageable level. INTERVENTION Independent: Identify patients perception of threat represented by the situation. Encourage patient to acknowledge and express fears. Provide opportunity for discussion of personal feelings or concerns and future expectations. RATIONALE Defines scope of individual problem, separate from physiological causes, and influences choice of intervention. Provides opportunity for dealing with concerns, clarifies reality of fears, and reduces anxiety to manageable level. Family members have individual responses to what is happening, and their anxiety may be communicated to patient, intensifying this emotion. EVALUATION GOAL MET After 4 hrs. Of nursing intervention s, the patient was able to report fear and anxiety are reduced to a manageable level.

Subjective: Fear related to Natatakot ako change in bigla na lang health status. akong dinugo as verbalized by the patient. Objective: Restlessness. Increased tension. Feelings of helplessness V/S taken as follows: T: 37.2 P: 90 R: 18 Bp: 110/80

Identify previous coping strengths of the patient and current areas of control or ability Encourage use of relaxation technique like deep breathing, guided imagery.

Focuses attention on own capabilities, increasing sense of control. Provides active management of situation to reduce feelings of helplessness.

ASSESSMENT SUBJECTIVE: Hindi na ako madalas dumumi nitong mga nakaraang araw as verbalized by the patient. OBJECTIVE: Abdominal pain, urgency, and cramping. Altered bowel sounds. V/S taken as follows: T: 37.1 P: 88 R: 18 BP: 120/80

DIAGNOSIS Constipation related to decreased dietary intake.

INFERENCE poor diet, lack of exercise, l peristalsis decreased l hard stools are formed. l increased colon pressure. l constipation

PLANNING After 8 hours of nursing interventions, the patient will establish or return to normal patterns of bowel functioning

INTERVENTION Independent: Determine stool color, consistency, frequency, and amount. Auscultate bowel sounds.

RATIONALE

EVALUATION After 8 hours of nursing interventions, the patient was able to establish or return to normal patterns of bowel functioning

Encourage fluid intake of 25003000 ml/day within cardiac tolerance. Recommend avoiding gasforming foods. Assist in perianal skin condition frequently, noting changes or beginning breakdown.

Assists in identifying causative or contributing factors and appropriate interventions. Bowel sounds are generally decreased in constipation. Assists in improving stool consistency.

Decrease gastric distress and abdominal distension. Prevents skin excoriation and breakdown.

Discuss use of stool softeners, mild stimulants, bulk-forming enemas as indicated. Monitor effectiveness. Encourage to eat high-fiber rich foods. Collaborative: Consult with dietitian to provide wellbalanced diet high in fiber and bulk.

Facilitates defecation when constipation is present.

To enhance easy defecation.

Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant to defecation.

ASSESSMENT

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION