NURSING DIAGNOSIS: Risk for constipation

related to:
  1. diminished defecation reflex associated with:
    1. suppression of urge to defecate because of lack of privacy and reluctance to use bedpan
    2. decreased gravity filling of lower rectum resulting from horizontal positioning;
  2. weakened abdominal muscles associated with generalized loss of muscle tone resulting from prolonged immobility;
  3. decreased gastrointestinal motility associated with decreased activity and the increased sympathetic nervous system activity that occurs with anxiety.
Desired Outcome
The client will not experience constipation as evidenced by:
  1. usual frequency of bowel movements
  2. passage of soft, formed stool
  3. absence of abdominal distention and pain, feeling of rectal fullness or pressure, and straining during defecation.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of constipation (e.g. decrease in frequency of bowel movements; passage of hard, formed stools; anorexia; abdominal distention and pain; feeling of fullness or pressure in rectum; straining during defecation).
  2. Assess bowel sounds. Report a pattern of decreasing bowel sounds.
  3. Implement measures to prevent constipation:
    1. encourage client to defecate whenever the urge is felt
    2. place client in high Fowler's position for bowel movements unless contraindicated
    3. encourage client to relax, provide privacy, and have call signal within reach during attempts to defecate (measures to promote relaxation enable client to relax the levator ani muscle and external anal sphincter, which facilitates evacuation of stool)
    4. encourage client to establish a regular time for defecation, preferably within an hour after a meal
    5. instruct client to increase intake of foods high in fiber (e.g. bran, whole-grain breads and cereals, fresh fruits and vegetables) unless contraindicated
    6. instruct client to maintain a minimum fluid intake of 2500 ml/day unless contraindicated
    7. encourage client to drink hot liquids upon arising in the morning in order to stimulate peristalsis
    8. encourage client to perform isometric abdominal strengthening exercises unless contraindicated
    9. if client is taking analgesics for pain management, encourage the use of nonnarcotic rather than narcotic (opioid) analgesics when appropriate
    10. increase activity as allowed
    11. administer laxatives or cathartics and/or enemas if ordered.
  4. Consult physician about checking for an impaction and digitally removing stool if client has not had a bowel movement in 3 days, if he/she is passing liquid stool, or if other signs and symptoms of constipation are present.
  5. Consult appropriate health care provider if signs and symptoms of constipation persist and appear to be an ongoing problem.