Alteration in Bowel Elimination: Constipation

Alteration in Bowel Elimination: Constipation

(_)Actual (_)Potential

Related
To:
[Check those that apply]
(_)Malnutrition
(_) Metabolic and endocrine disorders
(_) Sensory/motor disorders

(_) Stress
(_) Immobility
(_) Inadequate diet
(_) Irregular evacuation pattern

(_) Drug side effects

(_) Pain (upon defecation)
(_) Pregnancy
(_) Surgery
(_) Lack of privacy
(_) Dehydration
(_) Other:_____________________________

____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:

(
Must be present)
(_) Hard formed stool and/or defecation occurs fewer than three times per week.
Minor:

(
May be present)
(_) Decreased bowel sounds.
(_) Reported feeling of rectal fullness or pressure around rectum.

(_) Straining and pain on defecation.
(_) Palpable impaction.

 

Date &

Sign.

Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions

[[Check those that apply]

Date
Achieved:
  The patient will:

(_) Have soft formed stool by _____ and q ___ day(s).

(_) Patient and/or significant other will verbalize an understanding of method for preventing and/or treating constipation.

  (_) Assess abdomen for distention, bowel sounds q ___ hours.

(_) Assess bowel elimination q
___ hours.

(_) Asses factors responsible for constipation:

  • stress
  • discomfort
  • sedentary lifestyle
  • laxative abuse
  • debilitation
  • lack of time/privacy
  • drug side effect

(_) Promote corrective measures:

  • review daily routine
  • provide privacy/time
  • provide comfort
  • encourage adequate exercise

(_) Promote adequate dietary/fluid intake. Patient likes:
Fluids:_______________
____________________
Fiber foods:___________
____________________

(_) Initiate bowel program to promote defecation.

(_) Consult dietitian.

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature