CONSTIPATION Nursing Care Plan

Joseph is a call center representative with morning shifts. Because of his 9-5 work and being workaholic, he usually forgot to take his personal needs like urinating, drinking and even defecation. He is always an employee of the month and always get a lot of commissions however, he didn't notice something is going wrong with him and if he doesn't act fast it may lead to complication. Below is a sample of constipation nursing care plan of Joseph, a call center representative.

ASSESSMENT

Subjective:

"I'am having difficulty in defecation because of my dry stool," as verbalized by the patient.

Objectives:

I observed from the patient that he/she has a distended abdomen and upon palpation, the patient has a tender abdomen without palpable muscle resistance. Through percussion, I detected dullness in the abdomen. (We consider a patient that he/she had a distended abdomen when his/her belly is swelling, distended abdomen is usually called swelling of the abdomen. While tender abdomen is when you palpate the abdominal area and you feel that it is hard and had a mass.) His/her sample stool is hard-dry.

The patient's vital signs are taken and noted as follows: Body temperature is 37.2 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, pulse rate is 82 beats per minute. Respiratory rate and pulse rate is normal while the patient's body temperature is above normal. His/her blood pressure is categorized as pre-hypertention.

DIAGNOSIS

Constipation related to observed hard, formed stool as evidenced by distended abdomen and palpable abdominal mass. (Constipation is the condition of being unable to easily release solid waste from your body. Stool is a solid waste product of the body while the liquid waste is the urine. The process of removing waste products inside the body, either solid or liquid, is called excretion.)

PLANNING

After 8 hours of nursing intervention, the patient will regain normal pattern of bowel functioning. (Once a day is considered a regular bowel. One a week is considered the patient is constipated while five or more are a day is a condition which is called diarrhea.)

INTERVENTION

- Review your Joseph's dietary regimen and note if his diet is deficient in fiber. Fiber helps food to move through your digestive tract more quickly for healthy elimination so encourage Joseph to have a balanced diet that rich in fiber. Fiber-rich foods are whole foods, fruits and vegetables.

- Ask Joseph about his fluid intake and evaluate his hydration status. Encourage him to have adequate fluid intake because this will promote his passage to stool. Tell Joseph to drink at least 8 glasses of water everyday.

- There are other factors you should consider to Joseph such as activity level and exercise, pain in defecation, and bowel obstructions. (Did you know that sedentary lifestyle of Joseph may affect elimination patterns and activities beyond his body's limit reduces stimulation for contractions of intestines?) Pain in defecation is sometimes caused by hemorrhoids, it is the swelling of veins in the rectum and anus. Fecal impaction is one of the most causes of bowel obstruction.

- Encourage Joseph for treatment of underlying medical causes of constipation where appropriate to improve organ function, including his bowel. Administer enemas and/or digitally remove impacted stool and establish bowel program to include glycerin suppositories and digital simulation, as appropriate, when long-term or permanent bowel dysfunction is present.

EVALUATION

After 8 hours of nursing intervention, the patient regained the normal pattern of bowel functioning.

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