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ASSESSMENT NURSINGDIAGNOSIS

BACKGROUNDKNOWLEDGE

PLANNING NURSINGINTERVENTION

RATIONALE EVALUATION

Objective: With (+)

irregulardefecationwithin 2 to 3

days With hard stool With insufficient

physical activity With decreased

physical mobilityas bed rest

With signs of dehydrationsuch as:

Poorskinturgor

Dry skin

Risk forconstipationrelated toirregulardefecation habits

and decreasedmobility asevidenced bydefecating forafter 2 to 3 daysand characterizedby few hard andsmall stool.

Constipation is acondition inwhich bowelevacuationsoccur

infrequently, orin which thefeces are hardand small, orwhere passage of feces causesdifficulty or pain.The frequency of bowel evacuationvariesconsiderablyfrom person toperson and thenormal cannot beprecisely defined.

Short-term goal:After 1 to 3 days of nursingintervention, thepatient will at least

have a soft stooland have an urgeto defecate at leastevery other day.

Long-term goal:After days of hospitalization, thepatient willfacilitate themaintenance of elimination.

1. Assessedclientsconditionespeciallybowel

movementsand stoolcharacteristics.

2. Obtained vitalsigns and I & O.

3. Reviewedmedical historyand conditionsassociated withimmobility.

4. Auscultatedabdomen forpresence,location andcharacteristicof bowelsound.

5. Evaluatedcurrent dietary,fluid intake andimplications foreffect on bowelfunctions.

To identifyproblem of the clientscondition.

To have thebaselinedata forcomparisonandrecognitionof changeswithin VSresults.

To identifyconditionscommonlyassociatedwithconstipation.

To assessedbowelsoundsreflectingbowelactivity.

To identifyfactorsaffecting onbowelfunction,content of feces whichaffects

bowelmovement.

Goal unmet,patient wasntable to increasefrequency of defecation in

result, stoolwasnt observedafter the firstdefecation.

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6. Encouragedmovementswithin limits of the client assuch turningposition onbed.

7. Ascertainedfrequency,color,consistencyand amount of stool.

8. Regulated IVFas prescribeddrops perminute.

9. Discussed tothe patientsrelatives theimportance of elimination.

10. Provided safetyand comfort.

To stimulatecontractionsof theintestines.

Provides abaselinedata forcomparisonandrecognitionof changes.

To keeppatienthydrated asfluid intakeismonitored.

To helpincreasepatientsrelativesconcernaboutelimination.

To keeppatientcomfortableand avoidhealthhazards.