Nursing Diagnosis
Patient exhibits constipation related to deficient fiber and fluid intake, as evidenced by abdominal discomfort and tenderness,
... [Show More] defecation fewer than two times per week, a distended abdomen, generalized fatigue, and a palpable abdominal mass
Short term goal
To induce a bowel movement that relieves the patient's constipation, resulting in patient reporting relief and diminished pain, within an emergency department visit.
Interventions
1) Administer a mineral oil based enema with physicians order
2) Assess and fulfill patient needs for ambulating to the bathroom
3) Have patient ambulate the length of the hallway with patient care tech assistance
4) Provide patient with 500 ML of fluid and advise to drink over the next two hours
5) Tell patient to leave any outputs unflushed for examination
Data Collections
- Ask about pain rating, abdominal cramping, nausea, and dizziness
- ask about patient outputs, presence of stool, and sense of constipation
- evaluate any store for amount and qualities
- evaluate for physical signs of pain and or cramping
- perform dehydration tests. Skin turgor, dry mouth, urine hat collection, and follow up as necessary
chief complaint
-reports abdominal pain
-reports difficulty with bowel movement
asked about orientation
-oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain
-reports discomfort for the past 5 days
-reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain
-reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale
-reports 6/10 pain
asked about characteristics of pain
-describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors
-denies taking pain medication
-denies taking laxatives
asked about aggravating factors
-reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life
-recent difficulty participating in usual activities
-reports low energy
followed up on constipation
-constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea
recent diarrhea
followed up about diarrhea
-about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool
-denies mucus and blood in stool
asked about urination
-recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
asked about fluid intake
-decreased thirst
-decreased fluid intake for last few days
-typical fluid intake is 1-2 glasses water/day
-denies drinking caffeine
asked about contact with illnesses
-denies recent travel and exposure to food poisoning
asked about history of constipation
denies history
asked about typical bowel movements
-typically has BM almost every day
-stools usually brown, formed, soft
asked about allergies
-reports latex allergy
-denies med allergies
-denies food allergies
asked about pre-existing health conditions
-reports high BP
-diagnosed at 54
asked about relevant history of surgery
-c section at 40
-gall bladder removal at 42
-no post op complications
asked about home meds
-meds for high BP
-10 mg accupril daily at 8 am
-no OTC meds
asked about access to healthcare
-annual checkup with HCP
-last pap smear over 10 years
-level of health and activity is good
-denies STI testing
-last colonoscopy over 10 years
-denies finances as a barrier
-denies transportation as a barrier
asked about family and support system
-reports living with daughter and strong family support
asked about diet
-last meal was toast at breakfast
-typically eats 3 meals a day
-denies snacks
-typical breakfast is toast
-typical lunch is soup
-typical dinner is chicken or fish with rice
asked about fiber intake
-denies fiber supplements
-denies efforts to incorporate fiber in diet
-reports eating veggie every 1-2 days
-reports eating fruit ever 3-4 days
asked about typical activity level
-typically high level of mobility and independence
-reports typically having a moderated activity level
asked about substance abuse
-denies illicit drug use; smoking
-low alcohol consumption
followed up on alcohol
-drinks 1 night a week
-drinks 1 drink per sitting
-white wine [Show Less]