Patient Code Name: J Age: 27 Sex: F Date of Assessment: Nov 10, 2023

Chief Complaint/s: Pain

NANDA Nursing Diagnosis ( PES ): Risk for constipation related to abdominal muscle weakness as evidenced by labor and delivery.

NANDA Definition: At risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and /or passage of exessively hard, dry stool

ASSESSMENT/ CUES PLANNING INTERVENTIONS RATIONALE EVALUATION

(Goals & Objectives)

The planned care was partially met

as evidenced by
SUBJECTIVE DATA: Short-term: Independent: 1. To identify conditions
commonly associated with
After 2 hours of nursing a. Review medical, surgical, and
social history. constipation
intervention, the patient will ● Responses to intervention,
Change in usual foods or eating b. Auscultate abdomen for 2. To differentiate changes in
teaching, and actions
patterns; insufficient fiber/fluid presence, location, and bowel sounds reflecting
performed.
intake characteristics of bowel bowel activity.
a. Maintain effective pattern sounds reflecting bowel 3. To monitor dietary intake of ● Attainment or progress
of bowel functioning activity. patient. toward desired outcomes.
OBJECTIVE DATA: 4. Familial or culutral thinking
about elimination affects ● Verbalize understanding of
● Facial grimace After 6 hours of nursing Dependent: client's lifetime patterns. risk factors and appropriate
● Difficulty in position intervention, the patient will 5. To stimulate contractions of interventions or solutions
a. Evaluate current dietary and
changes the intestines. related to individual
a. Verbalize understanding of fluid intake and implications
● Guarding for effect on bowel function. 6. Discussing may help reduce situation
risk factors and appropriate
● Irritability b. Ascertain client's beliefs and concerns/anxiety about
interventions or solutions ● Demonstrate behaviors or
● Restlessness practices about bowel situation.
related to individual lifestyle changes to prevent
● Change in normal sleep eliminating, such as “must 7. Information can assist client
situation developing problem.
pattern have a bowel movement every
to make beneficial choises
● Decreased ability to b. Demonstrate behaviors or day or I need enema.”
when need arises
function c. Encourage activity and
lifestyle changes to prevent
exercise within limits of
● Vital Signs: developing problem.
individual ability
BP: 120/90mmHg
Temp: 36.3°C Collaborative:
RR: 24 cpm
a. Discuss physiology and
HR: 102 bpm acceptable variations on
O2 sat: 98% elimination.
b. Educate client/SO about safe
and risky practices for
managing constipation.