Name: Guiritan, Abigayle Therese R. Yr. and Sec.

: 2Nur-5 Clinical Instructor: Maam Perlas

Date: July 4, 2011 RLE 2

Assessment Subjective: The patient verbalized fear of defacation because of her fear of opening again her episiotomy. 2. The patient verbalized pain in her Perineal area. 3. The patient verbalized of having low fluid intake. Objective: 1. The patients 24 hour diet revealed that she lacks fiber in her diet. The patient was observed to having limited movement. It was revealed in the patients medication that she is taking Ferrous Sulfate which is an Iron supplement.

Diagnosis Risk for Constipation related to pain/ discomfort in the Perineal area.

Scientific Rationale Constipation is defined as having a bowel movement fewer than three times per week. It is also known as the cause of having painful defacation. Constipation can occur after having a baby. It can be caused by having birth, medications, lack of fluids, pain, fear of having a bowel movement, or lack of exercise.

Planning At the end of the four hour shift, the patient will be able to: 1. Verbalize understanding of etiology and appropriate interventions or solutions for individual situation. 2. Establish or regain normal pattern of bowel functioning.

Intervention Independent 1. Auscultate bowel sounds. Note consistency, and frequency of bowel movements and presence of abdominal distention. Determine usual elimination pattern or frequency, characteristics of stool- color, consistency, amount- manner of constipation, and use of laxatives. Review current medication regimen. Ascertain usual dietary pattern and food choices. Suggest adding fresh fruits, vegetable and fiber to diet within restrictions when indicated. Encourage or assist ambulation when enabled. Provide privacy at bedside commode and bathroom. Review the amount and type of fluid intake. Encourage fluid intake of 2,500 to 3,000 mL/day. 1.

Rationale Decreased bowel sounds; passage of hard-formed or dry stools suggests constipation and requires ongoing intervention to manage. Provides baseline for comparison, promotes recognition of changes, and helps to establish a preventative plan. Side effects of some drugs, such as iron products and some antacids, may compound problem. Although restrictions may be present, thoughtful considerations of menu choices can aid in controlling problem. provides bulk, which improve stool consistency. Activity may stimulate peristalsis, promoting return to normal bowel activity. Promotes psychological comfort

Evaluation

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The patient verbalized understanding of etiology and appropriate interventions or solutions for individual situation. the patient started to establish or regain normal pattern of bowel functioning.

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Collaborative