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