Name: Kristelie A.

Tilla-in, BSN 2Y1-12

Case: A male patient, 9 y/o with c/c of constipation

Assessment Diagnosis Planning Implementation Evaluation

Subjective data: Alter in body – After an hour – Assess body – After an hour
temperature related of nursing temperature of nursing
“I’m cold, I want to the presence of intervention, ever 20 min intervention,
something warm in bacteria in the blood the patient’s – Provide a quiet the client’s
my body,” as stated as manifested by body environment body
by thepatient. above normal temperature for the patient temperature
temperature (390C) will be to rest well decreased
Objective data: and increase in white decreased – Perform tepid from 390C to
– Temperature blood cell. from 390C to sponge bath to 37.60C.
(390C) 37.60C. decrease the
– Sweating patient’s body
– Decreased temperature – The patient
appetite – There will be – Increase fluid underwent
– Flushed skin decreased intake to decreased of
– Lethargy sweating of prevent sweating after
– Malaise the client dehydration half an hour of
– Remove nursing
excess intervention
clothing or
– After a day of blankets that – There was an
nursing make the increase in the
interventions, patient feel client’s
there will be hotter or appetite after
an increase in uncomfortable a day of
the client’s nursing
appetite interventions

– The goals were

met, therefore,
Name: Kristelie A. Tilla-in, BSN 2Y1-12
Case: A male patient, 9 y/o with c/c of constipation

the plan
should not
anymore be
revised
Name: Kristelie A. Tilla-in, BSN 2Y1-12
Case: A male patient, 9 y/o with c/c of constipation

Assessment Diagnosis Planning Intervention Evaluation

Subjective data: Constipation related – After a week of – Collect data on – After a week of
to malnutrition as performing patient’s perform
“I was not able to evidenced by hard series of dietary habits nursing
poop for three days formed stool and nursing and home interventions,
now, and a couple of defecation occurs interventions, remedies for the client was
days before that I less than three times the patient will constipation able to
was having difficulty per week. have normal – Initiate bowel defecate
in bowel movement bowel training without have a
and small, hard, stool movements at program normal bowel
and my tummy is least every two – Educate the movement for
aching now,” as to three days. client on need three days.
verbalized by the for fluid intake
patient. – A week after and foods high
performing in roughage
Objective data: series of – Give the client – The client did
nursing and overview not anymore
– Difficult bowel interventions, of the diet experience
movement the client will – Identify the fecal impaction
– Dry, small, not anymore types of foods after a week of
hard feces experience and fluids performing
– Absent bowel fecal impaction needed in the nursing
movement diet interventions
– Infrequent – The client will – Evaluate bowel
bowel eventually management – The client had
movement have a softer daily or at a softer
– Abdominal abdomen a outpatient visit abdomen a
pain couple of days couple of days
– Sluggish after the after the
– Abdominal nursing nursing
swelling interventions interventions