Question

Nursing Care Plan

Nursing Health History
Personal Data
Ms. Sy, 65 years old, Female residing at Montojo, Makati City. She is single, Filipino citizen and a
Roman Catholic believer. Her usual source of healthcare is at Ospital ng Makati.
Chief Complaint
"I noticed a significant delay on my bowel, and I don't know why?" as claimed by the client.
History of Present Illness
Five days prior to consultation, the client noticed a delay on her bowel habits. The client cannot
remember the exact date when the symptoms started. But according to her it started gradually since she
turned 60 years old. There is no associated symptoms or aggravating factors related to her symptom. On
the day of consultation, the client suddenly worried about her change in bowel habit, which prompted to
consult. She was examined at Ospital ng Makati , Out patient department.
Past Medical History
Ms. Sy has a complete immunization when she was a child. Common illness include fever, flu, then
cough and colds which is usually relieved at home. She never experienced any injuries. No records of
hospitalization and she does not take any form of medications.
Family History -
No heredofamilial disease such as asthma, diabetes, hypertension, alcoholism, tuberculosis etc.
Social History
She lives alone in her house and believe in the effects of herbal medications she does not have any
superstitious belief that can affect her health status. Ms. Sy finished her primary education in Cebu and
used to work as a sewer, even up to the present. According to her she never had any conflicts with her
neighbor. She also receive monthly pension from SSS and Philam Life.
Review of Systems
Psychological
The client views herself as a simple person gifted with a peaceful life. Even though she lives all
alone by herself she thinks that it is good enough for her. Sometimes she feels lonely when listening to
love songs since she never had a chance to get the best man for her. She also prefers to be alone for
some time and does not want to socialize when she is sad since most of her neighborhood have their own
family.
Elimination
The client urinates 5-6 times a day in scanty amounts with yellowish color without any discomfort.
She defecate 2 times a week, color brown in scanty amount and hard. According to her this is not her
usual characteristic of her bowel. She feels incomplete every time she defecates as if she wants to
excrete more. She does not perspire a lot.
Rest and Activity
She used to watch television and listen to the radio when she gets tired. Her usual Activity of Daily
Living includes cleaning her house, doing the chores and gardening. But for the last month she had
lessened her activity and prefers to stay inside her house because of glare on lights.
Safe Environment
Ms. Sy feels secure in her place since the Barangay Hall is just adjacent to her house. According
to her she seldom hear some trouble in their place since the Barangay Tanods are very active. She lives in
a house made of concrete material. She has no allergies to food, drugs and environment.
Oxygenation
She does not have any signs of respiratory distress and never had symptoms of difficulty of
breathing

Nutrition
The client used to eat root crops and tomato from her garden since this is one of her favorite
foods. She seldom drinks water and would prefer to have nganga in her mouth all day long. She also
verbalized, "Gusto ko nga matuto magluto at kumain ng masusustansyang pagkain eh, para libangan na
rin”, as verbalized by the client.
24 Hour Diet Recall
Breakfast: 1 Pandesal, 1 cup of coffee
Lunch: 1 cup rice, 1 tilapia,
1 glass of water
Dinner: 1 cup rice, 1 tinapa,
1 glass of water
B. Physical Examination
GENERAL APPEARANCE
The client has small body built, thin with stooped posture and coordinated body movement. She
is appropriately dressed, neat without body odor. No obvious signs of physical deformity or illness
noted. Her vital signs are: temperature= 36.1 OC (axilla), PR=65 bpm, RR= 17cpm, BP= 110/80mmHg. Client’s
height is 147cm and weighs 90 lbs.
MENTAL STATUS
She is conscious, coherent and cooperative with good affection. Oriented to time, place,
date and person. She responds appropriately and slowly in an understandable manner. Uses simple
words in communicating.
SKIN
Client’s skin color is light to deep brown, uniform in color with prominent veins on the arms and
toes. Sagging and wrinkling were noted. Brownish, circular age spots (lentigo senilus) was noted on the
volar area of both arms ranging from 1-2cm width. Skin temperature is warm within normal range.
Decreased skin turgor is noted. There are no lesions and fine white hairs are evenly distributed all over the
body.
HAIR
With white, straight hair at shoulder level, evenly distributed, thin silky resilient. No
infection/manifestation and dandruff seen. Absence of nasal, ear, eyebrow and axillary hair coarse is
noted.
NAILS
The nail plate had 160 angle, smooth texture, and pinkish with longitudinal ridges. Epidermis
is intact, capillary refills within 3 seconds.
HEAD AND FACE
With round normocephalic and symmetrical with frontal, parietal and occipital prominence. Hair
is evenly distributed, head contour is smooth with uniform consisteny; without nodules or masses. With
symmetrical facial movements and features. Wrinkles are also present.
EYE
Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the eyes is
intact without any discoloration; lids close symmetrically with 15-20 blinks per minute. The sclera is white,
palpebral conjunctiva is shiny and pinkish while bulbar conjunctiva is clear. No edema or tenderness
on the lacrimal glands. Opaque white ring around the iris (arcus senelis) is noted. There is some opacity
present on the lens. The pupils are equally round (3-4mm) and reactive to light and
accommodation. When looking straight ahead, client has difficulty in recognizing objects in the
periphery. Both eyes are coordinated; move in unison with parallel alignment (8 ocular movements).
The client is unable to read font 12 of printout and has a vision of 20/100. Glaring into lights is one of her concerns.

EAR
The auricles are brown in color, symmetrical and aligned with outer canthus of eye, about 10
from vertical view. Upon palpation, auricles are mobile, firm and non-tender; pinna recoils after it is
folded. Using an otoscope, distal 3~d contains thin hair follicles and glands; semitransparent and pearly
gray tympanic membrane. The client has difficulty in responding to normal voice and negative for
watch tick test. Normal for Rinnes and Webers test
NOSE
With symmetrical and straight nares, without discharge, flaring and uniform in color. Air moves
freely through the nares as the client breathe. Nasal mucosa is pink, clear without any lesions.
Nasal sinuses are non-tender
MOUTH AND OROPHARYNX
Outer lips has uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips and
buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She has 32 smooth and intact dentures,
moist and firm. The tongue is. at the center, pink color, with smooth lateral margins, no lesions, raised
papillae, moves freely without tenderness and nodules. Absence of papillae is noted. Salivary glands
is intact, pinkish in color without any lesions with light pink hard and soft palate positioned in the
midline with smooth posterior wall. Tonsils and uvula is not inflamed. Gag reflex is present.
NECK
Muscles are equal in size, head is in the center. Head movement is coordinated, smooth without
discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the
midline. Thyroid gland is not palpable but ascends during swallowing.
BREAST AND AXILLA
With brown, saggy,asymmetrical with fine glandular texture. There are no masses palpated.
Nipples are pinkish in color, dry and symmetrical. The axilla is color brown, dry without hair.
CHEST AND LUNGS
The anteroposterior to transverse diameter is in ratio of 2:1. with symmetrical chest expansion and
kyphotic spine. Skin is intact with uniform color and temperature. No tenderness and masses upon
palpation. With bilateral symmetry of vocal and tactile fremitus. Resonance is heard over the thorax.
Diaphragmatic excursion is 3cm. Costal angle is 80 and the ribs are 45. Upon auscultation, bronchial
(trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds (terminal bronchi) were
heard.
HEART
There are no masses and lesions in the skin. There is palpable pulsation at the left ICS (5th)
MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous with S1. The
apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during auscultation.
ABDOMEN
The color is uniform and the skin is unblemished. There are symmetric movements caused by
respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min without
arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No tenderness, relaxed
abdomen with smooth, consistent tension. The liver, bladder and spleen are not palpable.
UPPER AND LOWER EXTREMITIES
The muscles have equal size on both sides of the body. There are no contractures or fasciculation
present. Muscles are firm, smooth with coordinated movements and equal strength on both sides of
the body. The bones do not have any deformities (related to an injury), tenderness or swelling. Joints
move easily. There are no signs of tenderness, swelling, crepitation of the joints.

Answer 1

Based on Provided data ,according to patient physical examination,it suggest that patient having problem with defecation and it leada to reduce and disturbed bowel pattern. It may leads to constipation. Her diet intake shows that less fiber diet and less fluid intake.

Nursing diagnosis is : "Constipation related to change in digestive process as evidence by decrease bowel movements.

Nursing care plan.