I have to come up with a care plan for this pt I had several weeks ago. Has to be nutrition/elimination diagnosis.
82 year old female, was admitted with pneumonia, COPD. When I interviewed her, she said her normal bowel frequency was three times daily, has hemorrhoids, date of last BM 2 dys ago. She said probably because she is not at her home. Her bowel was distended, and I did listen to her, she did have bowel sounds x4.
medications: asa, blood thinners, vasotec, mvi, oscal, theodur,lasix, and administered senokot that morning to her.
Intake-800ml Out-500ml 4 hrs. Hgb 10.1 hct 30.3 Na 141, cl 104, K 3.0
I've come up with constipation, r/t decreased peristalsis secondary to: stress AEB last bm 2 dys ago, bowel distended, and pt states, "probably not going, because I'm not at home".
can someone critique this before i turn it in, please. Any suggestions would be appreciated, thanks.
Apr 28, '09
constipation r/t decreased peristalsis secondary to: stress aeb last bm 2 dys ago, bowel distended, and pt states, "probably not going, because i'm not at home"
the "secondary to" for the r/t part of the diagnostic statement is used for medical diagnoses that we want to sneak there and stress
is not a medical diagnosis unless the doctor diagnosed her with it. and, it is not logical that stress causes peristalsis to slow down. it is more likely that stress causes things to speed up in the gi track. so, i would remove secondary to: stress
from this diagnostic statement. another possibility here is that being more immobilized or the diet she is getting in the hospital has contributed to the constipation.
i don't like her statement, "probably not going, because i'm not at home".
it's because i've been a nurse a long time. it is just a suspicious statement. someone who has 3 bms a day and now hasn't had one for 2 days is doing something at home that she isn't able to do in the hospital. it makes me think that she isn't wanting to reveal what it is because it is not normal and she's hiding that information from you. i would really like to have a crack at questioning her. there are ways to get the information out of her. some people, at home, will take things to make sure they are pooping such as prunes, prunes and more prunes. or, they take laxatives.
i would just write this diagnostic statement as: constipation r/t decreased peristalsis aeb no bm x 2 days and distended abdomen.
there is an entire list of other symptoms for this listed on these two webpages. look under the sections entitled defining characteristics
for them. defining characteristics is nursing language for symptoms.
good luck with the remainder of this care plan.
Apr 28, '09
I don't have that pt anymore...so I'll never know. Being a new student, that never occurred to me, but from reading a lot of the posts on constipation, it looks like nurses run into this issue all the time.
Thanks for your help. I'm leaving the quote off of my diagnosis.