NURSING CARE PLAN -hirshprung dse - Nursing Crib

NURSING CARE PLANASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:“Hindi madumiang anak ko” (Mybaby is constipated)as verbalized bythe mother.Objective:• Altered bowelsounds.• Reports ofabdominalpain orcramping.• V/S taken asfollows:T: 36.5P: 130R: 30Constipationrelated tochanges indigestiveprocess.• Hirschsprung’sdisease(congenitalaganglionicmegacolon) isthe congenitalabsence of orarresteddevelopment ofparasympathetic ganglion cellsin the intestinalwall, usually inthe distal colon.Symptoms arerelated tochronicintestinalobstruction andusually appearshortly afterbirth but maynot berecognized untillater inchildhood or(rarely) inadulthood. Inthis order thelack ofcolorectalinnervationAfter 8 hours ofnursinginterventions,the patient willdemonstratechanges inbehavior asnecessitated bycausative andcontributingfactors.Independent:• Determine stoolcolor,consistency,frequency, andamount.• Auscultate bowelsounds.• Monitor intakeand output (I&O)with specificattention to foodor fluid intake.• Recommendavoiding gasforming foods.• Assess perianalskin conditionfrequently, notingchanges orbeginningbreakdown.Encourage orassist withperineal careafter each bowelmovement.• Discuss use ofstool softeners,mild stimulants,enemas as• Assists inidentifyingcausative orcontributingfactors andappropriateintervention.• Bowel soundsare generallyincreased inconstipation.• May identifydehydration,excessive lossof fluids or aidin identifyingdietarydeficiencies.• Decreasesgastric distressand abdominaldistension.• Prevents skinexcoriation andbreakdown.• Facilitatesdefecationwhenconstipated isAfter 8 hours ofnursinginterventions,the patient wasable todemonstratechanges inbehavior asnecessitated bycausative andcontributingfactors.

inhibitsperistalsis, andthe affectedportion ofintestinebecomesspastic andcontracted. Theinternal rectalsphincter failsto relay, whichpreventsevacuation offecal materialand gas andcauses severeabdominaldistention andconstipation.indicated. Monitoreffectiveness.Collaborative:• Consult withdietitian toprovide wellbalanced diethigh in fiber andbulk.present.• Fiber resistenzymaticdigestion andabsorbs liquidsin its passagealong theintestinal tractand therebyproduces bulk,which acts as astimulant fordefecation.