Careplan question (constipation)

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Hey everyone,

New to the site, was searching for help on doing a careplan on google and the site came up. My question is regarding about doing a careplan on using constipation as my diagnosis. The only data I have came from the patient's charts and subjective data from the patient. The drug chart states that he has been given quite a few laxatives for constipation. The other data I have was the patient telling me that he hasn't been able to go regularly ever since living at the hospital. What I'm curious about is if these would be legitimate data for me to use in my diagnosis.

I'm having trouble with coming up with any diagnosis, the other possible option is a diagnosis about his sarcoma, but I don't know what I could use as a diagnosis. The patient seems to be not troubled in using it and is already aware as to what it is for.

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Specializes in Med/Surg, Academics.
New to the site, was searching for help on doing a careplan on google and the site came up. My question is regarding about doing a careplan on using constipation as my diagnosis. The only data I have came from the patient's charts and subjective data from the patient. The drug chart states that he has been given quite a few laxatives for constipation. The other data I have was the patient telling me that he hasn't been able to go regularly ever since living at the hospital. What I'm curious about is if these would be legitimate data for me to use in my diagnosis.

You can definitely use what the patient said as subjective data for the diagnosis. About the info from the chart...if you used the fact that there are laxatives on the MAR, you're actually using the presence of an intervention as assessment data, and I would think that's a big no-no.

There has to be somewhere in the chart showing nursing assessment data re: having no BM.

I have a couple other hints for you that may or may not lead you to more assessment data, depending on your patient: take a closer look at his MAR, think about ways that peristalsis can be slowed down in a hospitalized patient, and think about his intake.

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Thanks for replying dudette. Would it be similar if I linked the side effects of his meds to why the patient is constipated? Then from there, think of interventions? Would it also be possible to say that the patient needs teaching as to why he's getting constipated? I appreciate the help.

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Specializes in Med/Surg, Academics.
Would it be similar if I linked the side effects of his meds to why the patient is constipated? Then from there, think of interventions? Would it also be possible to say that the patient needs teaching as to why he's getting constipated? I appreciate the help.

You can do all these things if it makes sense for your patient. Good luck!

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Thank you again dudette. Your help has been highly appreciated.

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Specializes in Gerontological, cardiac, med-surg, peds.

This site may be of help to you in your research: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=13

In *P *E *S (PROBLEM, ETIOLOGY, SIGNS/SYMPTOMS) format:

Constipation r/t ???? immobilization secondary to hospitalization; side effects of medications; side effects of disease state??? AEB pt states, "-------," No BM in ____ days.

GOAL: Pt will pass a soft, formed bowel movement without straining, according to his normal pattern (you need to figure out what that regular pattern is according to what the pt has told you - be specific [twice daily, every day, every other day, etc.] - and write that in your goal statement) throughout his hospital stay.

INTERVENTIONS: Student nurse/ nurse will......

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