Constipation TAHBSO

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CUES/DATA NURSING RATIONALE GOALS & INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Constipation Constipation is common After 1 hour of 1. Encourage and provide - Fluids will help soften the stool to allow After 1 hour of
Objective Data: related to effects of after surgery and can nursing interventions, daily fluid intake of 2000-3000 for easy passage along the colon. nursing interventions,
medications and range from a minor to a client will pass soft, ml/day. GOALS ARE MET as
Client had not had a surgery serious complication. firm stool and will manifested by client
BM for 2 days after Decreased mobility, verbalize measures 2. Increase patient’s physical - Ambulation strengthens abdominal passed soft, firm stool
surgery decreased oral intake, that will prevent activity by planning ambulation muscles that facilitate defecation. and verbalized
and opioid analgesics recurrence of periods if possible. measures that will
Client was prescribed a contribute to difficulty constipation. prevent recurrence of
laxative last 4/29/09, having a bowel 3. Assist in active/passive - Activities promote defecation. constipation.
Dulcolax, rectal supp. movement. In addition, ROM exercise.
given at 2045H irritation and trauma to
the bowel during surgery 4. Encourage increased fiber - Fiber passes through the intestine
Client on soft diet, to be may inhibit intestinal in diet: Mashed vegetables, essentially unchanged. When it reaches
shifted to DAT once movement for several oatmeals, etc. the colon, it forms a gel, which adds bulk to
with (+) BM days. If the abdomen is the stool, and makes defecation easier.
not distended and if the
patient does not have BM
by the second or third
post-operative day, the
physician should be Reference:
notified so that a laxative Nursing Care Plans, Gulanick, pp. 16-17
can be given in the
evening.

Reference:
Brunner and Suddarth’s
Textbook of Medical-
Surgical Nursing, 11th
Ed., p. 543

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