Week 5 Nursing Diagnosis and Planning Related to Bowel Elimination – Flashcards

Constipation Diarrhea Bowel Incontinence Self-Care Deficit: Toileting Disturbed Body Image

During the physical exam, the nurse assesses the abdomen: Is the abdomen flat, or is it distended? Are bowel sounds normal, hyperactive, hypoactive? Is the abdomen tender to palpation? While working with the patient at the bedside, the nurse notes: Any indication of possible abdominal pain (e.g., facial grimacing while rubbing abdomen) Does the patient appear to be straining while attempting to pass stool? What are the patient's stool characteristics? (e.g., soft formed, liquid, hard)

During the patient interview, the nurse: Asks for any pertinent information regarding the patient's bowel elimination. For example: When did you last pass stool? Describe your usual bowel habits. Attempts to identify potential barriers to achieving normal bowel elimination. For example: On a scale of 1 to 10, how would rate your pain? Do you have any history of hemorrhoids?

related to pain medication use, decreased fluid intake, and decreased mobility as evidenced by no stools for three days, hypoactive bowel sounds, and a firm, tender abdomen.

related to malabsorption as evidenced by hyperactive bowel sounds, bloating, cramping, and frequent loose, watery stools

related to anal sphincter dysfunction as evidenced by constant dribbling of soft and liquid feces, inability to recognize the urge to defecate, and fecal staining of underclothing.

related to hemiparesis and impaired mobility as evidenced by history of recent stroke, weakened right extremities, need for assistance for toileting, and restriction of bedrest.

related to faulty appraisal as evidenced by self-report of long-term constipation and daily use of laxatives.

This diagnosis should be considered when the patient has risk factors for constipation present but does not currently have constipation. For example: Poor fluid intake Low fiber intake Decreased intestinal motility Receiving medications or feedings that are known to cause constipation Decreased physical activity

Risk for Impaired Skin Integrity in patients experiencing: Bowel incontinence Constipation, which increases the risk for anal fissure (a tear in the anus) Ileostomy, which exposes skin to irritating digestive enzymes Example of nursing diagnosis statement: Risk for Impaired Skin Integrity related to bowel incontinence.

Fluid Volume Deficit in patients who have: Frequent diarrhea Certain ostomies (e.g., ileostomy or ascending colostomy) which cause unregulated liquid stools Example of nursing diagnosis statement: Fluid Volume Deficit related to prolonged diarrhea as evidenced by intake less than output, frequent watery stools, poor skin turgor, and dry mucous membranes.

Pain in patients experiencing: Hemorrhoids Anal fissures Diverticulitis Example of nursing diagnosis statement: Pain related to inflammation of hemorrhoids as evidenced by patient complaint of pain during bowel movements.

Disturbed Body Image in patients experiencing: Bowel diversion (e.g., colostomy, ileostomy) Bowel incontinence Example of nursing diagnosis statement: Disturbed Body Image related to bowel diversion as evidenced by refusal to discuss descending colostomy and restriction of bedrest.

Primary care provider (PCP) for the patient's medical prescriptions (medications, diagnostic tests, etc.) Wound, ostomy, and continence nurse (WOCN) for patients who have bowel diversions (ostomies) or issues with bowel incontinence Nutritionist for patients with specific dietary needs related to bowel elimination Mental health professional for patients experiencing anxiety or depression related to bowel elimination Physical therapist (PT) for patient requiring assistance with mobility related to bowel elimination

Maintaining normal elimination patterns Returning to previous levels of function Preventing risks associated with specific alterations

Goal: Patient will pass soft stools daily during hospitalization.

Goal: Patient will defecate formed stools within 24 hours of initiating prescribed therapy.

Goal: Patient's episodes of bowel incontinence will decrease within 48 hours of starting a bowel training program.

Goal: Patient will assist with self-care after toileting within two days.

Goal: Patient will participate in personal colostomy care during hospitalization.