Nursing Process Record

Nursing Diagnosis NANDA Definition Constipation r/t diuretic use, insufficient oral fluid intake, high-protein diet and prolonged bed rest.
Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool. Constipation is caused due to several different problems. Lack of exercise, poor diet, lifestyle, and daily routine play a role in causing constipation. Sometimes constipation is a part of a physiological condition like pregnancy. Some medications, such as diuretics, can also cause constipation. Change of habits and activity can cause constipation. High stress levels are also known to contribute to it. One of the primary problems that directly lead to constipation is dehydration. Lack of fluids in the water makes the feces hard. Diuretics are medications that are known to cause dehydration. The diuretic extracts water content from the blood and converts it into urine. The body loses a lot of fluids while taking diuretics. The frequent urination caused by it, decreases the water level in the blood. (OnlineMedicineTips.com)

Cause Analysis

Assessment Subjective Cues: Lisod kaayo i-libang. Dugay kaayo ko sa CR gabie. Nakatulog nalang si Lola og bantay sa gawas kay dugay kaayo ko naka human, as verbalized by the patient. Objective Cues: * On diuretics * Sweating

Interventions NIC: Bowel Management:

Constipation/Impaction Management* Fluid & Electrolyte Management 1. Evaluated usual

Rationale NOC: Bowel Elimination* Hydration: Symptom Control

Expected Outcome March 28, 2012: Client will maintain passage of soft, formed stool every 1 to 3 days without straining by the time of discharge.

dietary habits, eating habits, eating schedule, and liquid intake.

1. Change in

2. Assessed usual

pattern of

mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation.

* *

High-protein diet Prolonged bed rest

elimination; compared with present pattern. (Patient has defecated once in three days since admission at time of assessment. [3/27/12])

3. Encouraged a fluid intake of at least 5 glasses of liquids per day.

4. Provide laxatives, suppositories, and

(Weeks, Hubbartt & Michaels, 2000) 2. Normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is normal for each individual. (Weeks, Hubbartt & Michaels, 2000) 3. Cereal fibers such as wheat bran add additional bulk by attracting water to the fiber, so adequate fluid intake is essential. Increasing fluid intake to 1.5 to

enemas only as needed if other more natural interventions are not effective, and as ordered only; establish a client goal of eliminating their use.

5. Encouraged client

to resume walking and activities of daily living as soon as possible. Encourage turning and changing positions in bed, lifting the hips off the bed, performing rangeof-motion exercises, alternately lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching the arms away from the

2 L/day while maintaining a fiber intake of 25 g can significantly increase the frequency of stools in clients with constipation. (Weeks, Hubbartt & Michaels, 2000). EB: Incr easing fluid intake is not helpful if the person is already well hydrated. 4. Use of stimulant laxatives should be avoided because they result in laxative dependence and loss of normal bowel function. (Merli & Graham,

2003) body, and pulling in the abdomen while taking deep breaths. 6. Provided privacy during elimination. Laxatives and enemas also damage the surface epithelium of the colon. (Schmelzer et al, 2004) 5. Bed rest and decreased mobility lead to constipation, but additional exercise does not help the constipated person who is already mobile. When the client has diminished mobility, even minimal activity increases peristalsis, which is necessary to prevent constipation. (Weeks, Hubbartt & Michaels, 2000)

7. Assessed degree to

which patients procrastination contributes to constipation.

6. Patient may be

Care Plan Evaluation

reluctant to defecate if her privacy is compromised in a ward. (Weeks, Hubbartt & Michaels, 2000) 7. Ignoring the defecation urge eventually leads to chronic constip ation, because the rectum no longer senses, or responds to, the presence of stool. The longer the stool remains in the rectum, the drier and harder (and more difficult to pass) it becomes. (Weeks, Hubbartt & Michaels, 2000) PARTIALLY MET. The patient verbalized that her stool is softer and her time spent on the toilet seat has been reduced significantly. Further implementation of this care plan is necessary to further patients improvements.