c


  

ccccc ccc cc !

(Subjective/Objective Data
pertinent to this nursing
diagnosis)
NANDA diagnosis? Related
factors noted? Evidence if an
³actual´ problem?
!
 State outcome achievement in behavioral terms.
Explain how interventions were met or explain why
(Consider assessments, treatments, & Note: Continue , Change (specify), Discontinue
they were not.
teachings pertinent to diagnosis) POC

c"#
$% Constipation related to in 
 
 % 1. Bowel sounds auscultated every 8 hours. $   &
$
' 
    (
activity and narcotic usage as "#
$ %
³I haven¶t had a BM in 3 evidenced by pt complaint of no 1a, b, & c. Auscultate and document 2. Abdomen palpated as planned.
days´ BM for three days. bowel sound assessment every 8 hours Goal met. Patient had a bowel movement on
3. Questioned patient on August 28. August 28 & 29 after breakfast. SN assisted with
2 a, b, & c. Palpate for abdominal bedpan.
distention every 8 hours 4. Offered patient water, juice or tea on five different
³I usually go every day.´ times. Abdomen no longer distended.
3 a & c. Ask patient if he/she has had
a BM and about abdominal sensations 5. Read menu choices to patient and encouraged extra
every shift. vegetables and whole wheat bread.
³I feel so bloated.´  
)$
''
$ %
$
 % 6. Provided hot coffee and hot apple juice with (Indicate the effectiveness of your
breakfast. assessements/interventions and provide
 4 a, b, & c. Encourage patient to drink rationale.)
 at least 1500 -2000mL of liquid each 7. Discussed patient with dietitian who made
day suggestions for diet selections. 1, 2 &3 ± Effective timing of assessments.
  cc
5 a, b, & c. Assist patient with diet 8. Colace given as scheduled. 4. Effective ± stool soft.
Measurable? Realistic? Time
 selections to include high fiber/bulk
element noted? Pertinent to 9. Provided verbal and written information on high 5. Effective ± stool soft.
 diagnosis? foods. fiber diets, high fluid consumption, and overuse of
6. Offer hot liquids (tea or juice) at laxatives to patient. 6. Effective ± BM occurred after morning cup of
 Goal: hot coffee.
normal defecation times.
 1.The patient will establish a 7. Effective ± patient made more appropriate
7 a, b, & c. Consult dietitian for food
satisfactory bowel elimination choices for meals after meeting with the dietitian.
"#
$% preference availability
pattern by August 29.
 8 a, b, & c. Give stool softeners as 8. Effective ± soft formed stool.
a.e.b.
prescribed with a full glass of water. 9. Unable to determine because not enough time
-Abdomen firm
a) Patient will verbalize having a has lapsed since teaching to determine if the
9. a,b, & c. Teach patient importance
-Hypoactive bowel sounds BM. patient¶s choices will prevent future constipation
of high fiber diet, fluid intake, and
overuse of laxatives or enemas. bouts.
-Bedrest order b) Decreased abdominal
distention.
-Receiving Lortab and
Morphine sulfate around c) Patient will verbalize feeling (
'
(
 (&  & %* 
the clock less bloated +
&" ,'&
 -
Continue with POC as described to prevent re-
development of constipation. Reinforce teaching
rather than repeating the full teaching component.
Decrease abdominal assessments to once/shift.