Assessment Diagnosis Inference
Subjective: Constipation Constipation is a very
related to common condition that
The client’s dehydration affects people of all ages.
grandmother and poor When you are
stated “ hindi pa eating habits constipated, you feel that
nga siya as evidence you are not passing
dumudumi simula by absence stools (feces) as often as
nung nahospital of stool. your normally do, or that
siya ngayon. Mga you have to strain more
apat na araw na than usual, or that you
ata.” are unable to completely
empty your bowels.
Objective: Constipation can also
cause your stools to be
o weak in unusually hard, lumpy,
appearance large or small. The
severity of constipation
o The client has a can vary greatly. Many
pale conjunctiva people only experience
, lips and palms constipation for a short
period of time with no
o U: 2 O:0 lasting effects on their
health. For others,
constipation can be a
o T: 36.9 chronic (long-term)
P: 125 condition which causes
R: 24 significant pain and
BP: 100/70 discomfort. Chronic
constipation can also
lead to complications,
such as fecal impaction
(where dry, hard stools
collect in your rectum) or
fecal incontinence
(where you incoluntarily
leak liquid stools around
solid impacted stools.)
Planning Intervention Rationale Evaluation
After 8 hours of Independent: After 8 hours of
nursing  Determine stool  Assists in identifying nursing interventions,
intervention, color, consistency, causative or the client was able to
the client will frequency and contributing factors establish or return to
establish or amount. and appropriate normal patterns of
return to interventions bowel functioning.
normal
patterns of  Auscultate bowel  Bowels sounds are
bowel sounds generally decreased
functioning. in constipation.
 Encourage  Sufficient fluid
increased fluid intake is necessary
intake of 2500 – for the bowel to
3000 ml/day within absorb sufficient
cardiac tolerance. amounts of liquid to
promote proper
stool consistency.
 Recommend  Decrease gastric
Avoiding gas- distress and
forming foods such abdominal
as nuts, peas and distension.
spicy foods.
 Instruct client on a  Fiber absorbs water,
high-fiber diet, as which adds bulk and
appropriate. softness to the stool
and speeds up
passage through the
intestines.
 Discuss use of stool
softeners, mild
stimulants, bulk  Facilitates
defecation when
forming laxatives or
constipation is
enemas as
present.
indicated. Monitor
effectiveness.
The treatment for
constipation is usually
very effective, although
in some cases it can take
several months before a
regular bowel pattern is Collaborative:
re-established.
 Encourage to eat
high-fiber rich  To enhance easy
foods. defecation.
 Consult with
dietitian to provide  Fiber resists
well-balanced diet enzymatic digestion
high in fiber and and absorbs liquids
bulk. in its passage along
the intestinal tract
and thereby
produces bulk,
which acts as a
stimulant to
defecation.