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Nursing Care Plan Constipation

Nursing Care Plan Constipation

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Published by: bmrose37 on Apr 25, 2010
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04/16/2013

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NURS240L Nursing Process Assignment Student Name___________Brian Rose_________ 
 Nursing Care Plan for Priority Nursing Diagnosis Rm#______J.P._____ _____ 
Assessment
(Your findings from prep day and days1&2 that relate to the problem. Include dates collected)
 
Planned Interventions
 
(Nursing carethat will assist to resolve problem. Date when done.)
Rationales
 
(Why intervention is appropriate, what it accomplishes)
 
Subjective
(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” 
Objective
(Data)
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
 
Nursing Diagnosis
(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
Outcomes
 
(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.
Evaluation
 
(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
 
423 6
 
Criteria for Nursing Process Assignment
1. Assessment1.Is subjective data in the client’s or significant other’s own words or accurately paraphrased?2.Is objective data in the form of specific measurements from student’s assessment (ie, resp rate, breathsounds, wound measurement, etc) and diagnostic information from the chart? Are dates included?3.Does data relate ONLY to the problem identified in nursing diagnosis?4.Does data adequately support the nursing diagnosis or is additional data needed?SubjectiveObjective2. Nursing Diagnosis1.Does the nursing diagnosis accurately describe the problem or risk identified in the assessment?2.Is the nursing diagnosis NANDA?3.Does the “related to” section describe the etiology (cause) of the problem (in physiological terms)?4.If “high risk for” diagnosis, are the risk factors listed instead of “related to” section? Nursing Diagnosis3. Outcomes (Use action verbs only. You must be able to use outcomes in the evaluation step to measureclient’s response to nursing interventions.)1.Are outcomes specific, realistic, measurable and have an appropriate and realistic time limit?2.Are there baseline measurements for all outcomes in the assessment?3.Do outcomes demonstrate improvement or at least no worsening of the problems?4.Do outcomes reflect changes expected as the result of nursing interventions?Outcomes4. Interventions: List references (Text & page#)1.Do nursing interventions address the identified problem?2.Do interventions help resolve the problem?3.Do interventions best accomplish the outcomes?4.Are interventions individualized to client (“O2 as ordered” would not be individualized but “O2 at 2L per NC” would be.)5.Are interventions specific enough? (“Increased activity” would not be specific but “Walk length of hallway qid” would be.)6.Are references listed?7.Have interventions been done? Date when done added to intervention?Interventions5. Rationales1.Do rationales explain why the intervention is appropriate to resolve the problem?2.Do rationales explain what the rationale accomplishes?Rationales6.Evaluation (Determines effectiveness of plan of care and addresses outcomes.1.Were outcomes evaluated by reassessment?2.Were specific findings reassessed and listed?3.Did the outcome (change) occur? Were outcomes met? If not, why?Evaluation

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