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ASSESSMENT Assess and document usual pattern of elimination then compare it with present pattern. Take in to consideration the following characteristics: size, frequency, color, odor and quality. The "Normal" frequency of passing stool varies from twice daily to once every third or fourth day. Assess and document for history of neurologic diseases, for example multiple sclerosis and Parkinsons disease. Assess current use of medication that may contribute or cause constipation. Assess dependency on enemas for elimination Assess for anxiety/fear with regards to pain. Assess for laxative use, type, and frequency Assess usual dietary habits, eating habits, eating schedule, and liquid intake prior to hospitalization. Evaluate activity level. Evaluate the degree of patients tendency to delay the defecation that may contribute to constipation. Explore the possible causes of delayed onset/absence of effluent. Auscultate for bowel sounds Inspect perianal skin condition frequently, noting changes or beginning of skin breakdown. Assist patient with perineal care after each bowel movement (BM). Monitor and document intake and output (I&O) with specific attention to food/fluid intake.
Monitor and document laboratory studies as indicated, e.g., electrolytes. Provide privacy for elimination (e.g., access to bathroom facilities with privacy during work hours or use of bedpan).

PLANNING Patient or caregiver will articulate procedures that will avoid recurrence of constipation. Patient will demonstrate changes in behaviors or lifestyle, as necessitated by causative, contributing factors. Patient will exhibit active bowel sounds or peristaltic activity. Patient will pass soft, formed stool at a regularity perceived as "normal" by the patient. Patient will pass stool of soft or semiformed consistency without straining.

INTERVENTION Assist in removal of fecal impaction digitally Encourage daily fluid intake of 2000 to 3000 ml/day (2 to 3 liters/day), if medically not contraindicated. Encourage to establish a regular time for elimination. Instruct patient to increased fiber in diet (e.g., raw fruits, fresh vegetables, prunes, prune juice, cold cereal, and bean products); a minimum of 20 g of dietary fiber per day is essential to promote good bowel. Support physical activity and regular exercise (e.g., isometric abdominal and gluteal exercises). To minimize discomfort, suggest the following measures: o Warm sitz bath o Hemorrhoidal preparations. These aids in shrinking swollen hemorrhoidal tissue. The following should be employed for hospitalized patients,: o Allow patient adequate time to relax. o Familiarize and reorient patient to location of bathroom and encourage use, unless medically contraindicated. Provide a warmed bedpan to bedridden patients and assist patient to assume a high-Fowlers position with knees flexed. Provide curtain off the area. Consult dietitian if necessary


Subjective and Objective Educative (Edx) Data clarify or reinforce to patient and Abdominal significant others the importance of the distention following: Abdominal 1. A balanced diet that contains adequate pain/rectal fiber, fresh fruits, vegetables, and grains is fullness, nausea essential. Twenty grams per day is Anorexia recommended. Change in 2. Adequate fluid intake. Drink 8 glasses/day frequency, or 2000 to 3000 ml/day. This facilitates consistency, and defecation. amount of stool 3. Avoid gas-forming foods. Decreases gastric Decreased bowel distress and abdominal distention. sounds 4. Privacy for defecation Dull headache, 5. Regular exercise/activity. Regular activities restlessness, and promote better peristalsis. depression 6. Regular meals. Successful bowel training Frequent but relies on routine. nonproductive 7. Regular time for evacuation and adequate desire to defecate time for defecation. Regular time should Increased be established to monitor patients abdominal girth elimination progress. Nausea and vomiting Discuss the use of pharmacological agents Passage of hard, as ordered, as in the following: dry stool 1. Bulk fiber (Metamucil and similar fiber Passage of liquid products). These increase fluid, gaseous, fecal seepage and solid bulk of intestinal contents. Straining at stools 2. Chemical irritants (e.g., castor oil, Verbalized pain or cascara, Milk of Magnesia). These drugs fear of pain cause irritation of the bowel mucosa that result to rapid propulsion of contents of small intestines. 3. Oil retention enema. This causes the stool to soften. 4. Stool softeners (e.g., Colace). This lubricates intestinal mucosa and soften stool for easier evacuation. 5. Suppositories. These help in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.

Difficulty holding voiding when urge to void develops? No__ Yes__ Have time to get to bathroom: Yes__ No__ How often does problem reaching bathroom occur? SUBJECTIVE 1. What is your usual frequency of bowel movements? _________________ a. b. Have to strain to have a bowel movement? No__ Yes__ Same time each day? No__ Yes__ OBJECTIVE 1. Auscultate abdomen: a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__ g. h. i. Retention: No__ Yes__ Describe: _____________________________ Pain/burning: No__ Yes__ Describe: ___________________________ Sensation of bladder spasms: No__ Yes__ When? ________________

2. Has the number of bowel movements changed in the past week? No__ Yes__ Increased?__ Decreased?__ 3. Character of stool a. b. c. Consistency: Hard__ Soft__ Liquid__ Color: Brown__ Black__ Yellow__ Clay-colored__ Bleeding with bowel movements: No__ Yes__

2. Palpate abdomen: a. b. c. d. (coughing, e. 3. Rectal Exam: Tender: No__ Yes__ Where?_________________________________ Soft: No__ Yes__; Firm: No__ Yes__ Masses: No__ Yes__ Describe: _______________________________ Distention (include distended bladder): No__ Yes__ Describe: _______ Overflow urine when bladder palpated? Yes__ No__

4. History of constipation: No__ Yes__ How often? ____________________ 5. History of diarrhea: No__ Yes__ When?___________________________ 6. History of incontinence: No__ Yes__ Related to increased abdominal pressure aughing, sneezing)? No__ Yes__ 7. History of travel? No__ Yes__ Where?____________________________

a. 8. Usual voiding pattern: b. a. b. c. d. e. f. Frequency (times per day) ____ Decreased?__ Increased?__ c. Change in awareness of need to void: No__ Yes__ Increased?__ Decreased?__ d. Change in urge to void: No__ Yes__ Increased?__ Decreased?__ e. Any change in amount? No__ Yes__ Increased?__ Decreased?__

Sphincter tone: Describe: ____________________________________ Hemorrhoids: No__ Yes__ Describe: ___________________________ Stool in rectum: No__ Yes__ Describe: _________________________ Impaction: No_- Yes__ Describe:______________________________ Occult blood: No__ Yes__ Location: ___________________________

4. Ostomy present: No__ Yes__ Location: ___________________________ Color: Yellow__ Smokey__ Dark__ Incontinence: No__ Yes__ When? _____________________________