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Careplan VII_with report_revised.docx - Nursing Care Plan...

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Nursing Care Plan (NUR 2115)Completion ChecklistAssessmentComments1.Assessment data is complete and accurate andincludes subjective and objective data.2. Identifies abnormal lab and diagnosticfindings with explanation for abnormalfindings as it relates to patient diagnosis.3. Medication information is complete.4. Pathophysiology completed on pertinentdiagnosis.Nursing Diagnosis5. A minimum of 3 NANDA nursing diagnosesare listed and 2 are worked out.6. Includes all 3 parts (stem, related to or R/T,and as evidenced by [AEB] for actualdiagnosis).7. Diagnosis is appropriate for assigned patient.8. Nursing Diagnoses are prioritized and numbered.Planning9. Realistic short-term patient goals listed.10. Goals are measurable with minimum (3)outcome criteria (AEB)Implementation11. A minimum of 5 interventions (2 assessment,2 nursing care,1 teaching).12. Interventions are specific and individualized tothe patient.13. Interventions are measurable and realistic.Evaluation14. Evaluated client responses to interventions.15. Evaluated short term goals as met, unmet, orpartially met and reason goals were unmet orpartially met. (outcome criteria addressed)16. Stated continuation, modification, or completionof plan.GradeSatisfactoryNeedsImprovementUnsatisfactoryI have verified that the attached paperwork meets the required assignment objectives, and it is ready for submission forgrading.Rebecca Jane PughRebecca Jane Pugh02/20/2022Student SignaturePrinted Student NameDate________________________________________________________Instructor SignatureDateDepartment of Nursing Education
Associate Degree NursingNursing Course:NUR 2115Semester:Spring 2022Report Title or Subject:Careplan VII with ER ReportDate of Care:02/22/2022Instructor:Anna Busby, RN, MSNRIGHT OF OWNERSHIP:This paper is being presented as a true and accurate representation of my work, research, and study. No part ofthis document is a paraphrase, quote, or creation of another individual unless correctly cited per ADN approvedcitation format. I understand that any variance in citation or referencing can be considered academicmisconduct.Print Name:Rebecca Jane PughDate:02/22/2022Signature:Rebecca Jane Pugh
PathophysiologyMedical Diagnosis/Patho:The colon absorbs water fromstool, making it harder and more challenging to pass the longerit sits in the colon. Eventually, stool becomes so impacted, thesmooth muscles of the colon must stretch to accommodate themass, which further decreases colon emptying. The cycle ofstool holding, removal of water from the stool, and stretchingof the smooth muscles in the intestine, results in hard stoolsthat are large and painful to pass, known as fecal impaction.Etiology:Consciously or unconsciously holding stools ratherthan emptying the colon can lead to fecal impaction. Thepediatric patient may be active and ignore the urge to defecatewhile playing or does not feel comfortable using the bathroomat school or in public.

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Nursing, Jennifer, Rebecca Jane Pugh

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