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Original Question
What are the short and long term nursing objectives/goals and the short and long term nursing evaluations of this given case scenario? (Cues, Nursing Diagnosis and Nursing Intervention are already stated) A 7 years male child presented with a chief complaint of no BM for one week. Denies nausea. No vomiting episodes were reported. Denies pain. VS 110/60, 36.8 AX, 98bpm, 22rpm. With protuberant ABD. With hypoactive BS. ABD non-tender, soft non-rigid. Last BM last Feb. 18, 2020, to minimal light brown hard stool. Cues: The client denies nausea and pain. The patient had an experience of minimal light brown hard stool or pain with defecation. Nursing Diagnosis: Constipation may be related to hard-formed stool and the development of fecal impaction. Nursing Intervention Independent: – Determine stool color, consistency, frequency, and amount. Rationale: Assists in identifying causative or contributing factors and appropriate interventions. – Auscultate bowel sounds. Rationale: bowel sounds are generally decreased in constipation. – Instruct the client on a high-fiber diet, as appropriate. Rationale: Fiber absorbs water, which adds bulk and softness to the stool that speeds up passage through the intestines. – Discuss the use of stool softeners, mild stimulants, bulk-forming laxatives, or enemas as indicated. Monitor the effectiveness. Rationale: Facilitates defecation when constipation is present. Dependent: – Evaluate is taking any medication or drugs. Rationale: that could be exacerbated by constipation. Collaborative: – consult with a dietitian to provide a well-balanced diet high in fiber and bulk. Rationale: fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract thereby producing bulk, which acts as a stimulant to defecation. – establish a bowel program to include predictable interval timing for colostomy irrigation or toileting. Rationale when long-term or permanent bowel dysfunction is present.
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