NURSING CARE PLAN
ASSESSMENT
Subjective: “Hindi madumi ang anak ko” (My
baby is constipated)
DIAGNOSIS
Constipation related to changes in digestive process. •
INFERENCE
Hirschsprung’s disease (congenital aganglionic megacolon) is the congenital absence of or arrested development of parasympatheti c ganglion cells in the intestinal wall, usually in the distal colon. Symptoms are related to chronic intestinal obstruction and usually appear shortly after birth but may not be recognized until later in childhood or (rarely) in adulthood. In this order the lack of colorectal innervation
PLANNING
After 8 hours of nursing interventions, the patient will demonstrate changes in behavior as necessitated by causative and contributing factors.
INTERVENTION
Independent: • Determine stool color, consistency, frequency, and amount. • •
RATIONALE
Assists in identifying causative or contributing factors and appropriate intervention. Bowel sounds are generally increased in constipation. May identify dehydration, excessive loss of fluids or aid in identifying dietary deficiencies. Decreases gastric distress and abdominal distension. Prevents skin excoriation and breakdown.
EVALUATION
After 8 hours of nursing interventions, the patient was able to demonstrate changes in behavior as necessitated by causative and contributing factors.
as verbalized by the mother. Objective: • • Altered bowel sounds. Reports of abdominal pain or cramping. V/S taken as follows: T: 36.5 P: 130 R: 30
Auscultate bowel sounds.
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Monitor intake and output (I&O) with specific attention to food or fluid intake.
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Recommend avoiding gas forming foods. Assess perianal skin condition frequently, noting changes or beginning breakdown. Encourage or assist with perineal care after each bowel movement. Discuss use of stool softeners, mild stimulants, enemas as
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Facilitates defecation when constipated is
inhibits peristalsis, and the affected portion of intestine becomes spastic and contracted. The internal rectal sphincter fails to relay, which prevents evacuation of fecal material and gas and causes severe abdominal distention and constipation.
indicated. Monitor effectiveness. Collaborative: • Consult with dietitian to provide well balanced diet high in fiber and bulk. •
present.
Fiber resist enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant for defecation.