Nursing Care Plan-Scenario #2 Scenario: A 26 year old female is in Day #3 of pos
ID: 244601 • Letter: N
Question
Nursing Care Plan-Scenario #2 Scenario: A 26 year old female is in Day #3 of postpartum care from delivering a healthy baby girl via C-section. She reports to you that she "has not had a bowel movement for 5 days. " She says she has been "straining" and is having difficulty passing stool and when she does it is a "very hard, small ball." In addition, she feels "a lot of pressure" in her rectum and is having pain from hemorrhoids that she developed in the last trimester of pregnancy. She says that she is "afraid to have a bowel movement because of the pain caused by the hemorrhoids." The patient received many narcotics during and after the delivery Temperature-98.9 F oral Pulse-80 02 Sat-98% RA BP-150/80 Respirations-22Explanation / Answer
Assessment
Subjective data:Patient says that she is having constipation and pressure on rectal area since 5 days and having complaints of haemorrhoid since antenatal peroid. Due to the fear of haemorrhoids pain she avoid straining at defecation.
Objective data: passing hard stool. Straining at stools. Decreased bowel movement while auscultation.
Diagnosis: Constipation related to overuse of narcotics before and after delivery as evidenced by hard stool, pain while passing stools, straining at defecation and fear of haemorrhoids pain to pass stool.
Goal
Short term goal: 1. patient will be relieved from constipation as evidenced by she said that she has passed motion without difficulty.
2. Patient will be relieved from constipation as evidenced by she identifies the measures that treat constipation.
Long term goal: patient will be relieved from constipation as evidenced by she verbalizes the measures to prevent recurrence of constipation.
Implementation
1. Checked the usual elimination pattern like frequency and consistency of stool- To plan interventions.
2. Took account of a norcotic use, type and frequency- To regulate its usuage in order to reduce the side effect of constipation.
3. Checked dietary habit like eating schedule and liquid intake- As interruption of normal schedule leads to constipation.
4. Evaluated fear of pain for defecation- Haemorrhoids pain leads to decreased straining effort to pass stool.
5. Encouraged fluid intake 2000-3000 ml per day- To keep fecal mass soft.
6. Encouraged to take fiber containing diet like spinach at least 20g per day- As it makes defecation easier.
7. Adviced for physical activity- As movement promote peristalsis.
8. Provided warm sitz bath to the patient- To reduce haemorrhoids size.
Evaluation
Met: Patient passed stools without straining.
Not met: Haemorrhoids not healed completely.
Reassess: The condition of haemorrhoids. Assess drugs used to treat haemorrhoids.
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