Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Client expressed she didn’t want to move “anymore than she has to.” Also indicated, “aching, constant” pain in the back.

Hx of DM II, CAD

Objective:

Temp:  101.0

Pain 6/10 in back

Hypoactive Bowel sounds

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

Client is NPO

Elevated blood glucose (185)

Client is on Atorvastatin, Oxycodone

No BM within past 6 days

Post-CVA

Problem

Constipation

Long Term:

Client will maintain passage of soft, formed stool every 1-3 days without straining by [date], 14:00.

-Palpate the abdomen for distention, percuss for dullness, and auscultated bowel sounds.

-Check for impaction, if present, perform digital removal per physician’s order

-Medicate client for pain and encourage movement from bed to chair if tolerated.    Encourage frequent position changes in bed, as well as ROM activities that can be done in bed.  Bed rest and decreased mobility lead to constipation, even minimal activity increases peristalsis (Weeks, Hubbart & Michaels, 2000).

-Facilitate consultation with nutritionist.  Optimizing nutritional intake is needed to promote digestive functioning (Russell, 2001).

R/T

Decreased activity, hx of stroke, medications (Atorvastatin, Oxycodone), decreased motility, and imbalanced nutrition

Short Term:

Client will identify measures that prevent or treat constipation by [date], 13:30.

-Assess current level of knowledge r/t measure to prevent and treat constipation.

-Review the client’s medications.  Many medications are associated with chronic constipation including opiates and antidepressants (Talley et al, 2003).

-Explain the importance of adequate fiber intake, fluid intake, and activity.

-Teach client to promptly respond to defecation urge.

All interventions to be evaluated [date], 16:00.

AEB:

Left side extremity weakness, right side hemiparesis, altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), elevated BUN (41), elevated creatinine (1.73), dysrhythmias, altered respiratory rate (24 decreased Hgb (10.2), decreased albumin (2.0), elevated blood glucose (185) and client is NPO.