NURS240L Nursing Process Assignment Student Name___________Brian Rose_________
Nursing Care Plan for Priority Nursing Diagnosis Rm#______J.P._____ _____
(Your findings from prep day and days1&2 that relate to the problem. Include dates collected)
(Nursing carethat will assist to resolve problem. Date when done.)
(Why intervention is appropriate, what it accomplishes)
(Client states r/t problem)
Client states “I haven’thad a BM since the myC/S”Client states “the time between going to the bathroom is more thannormal”
Client is 2 days P.O.Taking opiate analgesics(Oxycodone) every 4hrsClient is apprehensiveabout ambulation andslow in generalmovements even while at bedrest. Possibly relatedto fear of painIntake was 480ml duringmy shift. No BM to date while in postpartum.Client on REG. diet.Eating 100% of breakfast
Encourage regular intake of food emphasizing foodshigh in fiber i.e. fruits such as raisins, apples and bananas, grains and cereals, leafy greens
Assess current activity level and tolerance. Include pain level every two hours and administer analgesics per physician’s orders.
Evaluate current medication usage that maycontribute to constipation. Educate client about sideeffect of use.
Evaluate fear of pain
Encourage daily fluid intake of 2000 to 3000 ml/day,if not contraindicated medically.
Encourage ambulation with assist as tolerated.
Educate client about a general pattern of constipationfollowing pregnancy.
Suggest the following measures to minimize rectaldiscomfort: use of Tucks pads to relievehemorrhoidal and perineal pain. Use of ice packs torelive pain associated with episiotomy
The bowels tends to be sluggish after birth becauseof the lingering affects of progesterone, decreasedabdominal muscle tone, and bowel evacuationassociated with labor and birth process
Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation.
Prolonged bed rest, lack of exercise, and inactivitycontribute to constipation.
Opioid analgesics and iron supplements taken pre/postpartum can contribute to constipation
Women who have had episiotomy, lacerations or hemorrhoids may tend to delay elimination for fear of possible pain. Delaying bowel movements mayincrease constipation and subsequently cause more pain
Dehydration compounds and contributes toconstipation.
Ambulation strengthen abdominal muscles thatfacilitate defecation.
Pain relief may reduce anxiety which is associatedwith such conditions and promote desire for elimination
(Problem identified in assessment)
Impaction; obstipation r/t pregnancy d/t decreasedmobility and use of opioid analgesics.
Reference w/page #s: Nursing Care Plan pg 46-48 Old’s pg 1045
(Specific to client & Nsg Dx, realistic, measurable, and time limited with baselinedata in Assessment)
Client will verbalize at least 3 means of promoting peristalsis by end of shift4/16/10.
(Were outcomes accomplished? If not, why)
Date & Time:
On 4/16/10 at 0830, Client met outcome by stating “drinking plenty of water,eating foods high in fiber, and getting out of bed and moving around”1