Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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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
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Problem
Constipation
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Long Term:
Client will maintain passage of soft, formed stool every
1-3 days without straining by [date], 14:00.
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-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).
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R/T
Decreased activity, hx of stroke, medications (Atorvastatin, Oxycodone), decreased
motility, and imbalanced nutrition
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Short Term:
Client will identify measures that prevent or treat constipation
by [date], 13:30.
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-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.
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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.
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