Postpartum Care Plan

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My diagnosis 1 is Constipation related to irregular bowel movement as evidenced by the colace that was prescribed.

The colace prescribed is not the evidence. Your assessment findings are used as evidence.

So how do you rephrase this?

My diagnosis 1 is Constipation related to irregular bowel movement as evidenced by the p/t remark of her reluctance to bowel not to strain her hemophilia surgery.

So how do you rephrase this?

My diagnosis 1 is Constipation related to irregular bowel movement as evidenced by the p/t remark of her reluctance to bowel not to strain her hemophilia surgery.

Your related to factors are specific to this pt... not irregular BMs. Constipation IS a form of irregular BM.

In this case, it *could* be r/t: decreased GI motility postop (although I'm confused... DID she have surgery? An episiotomy implies it was a lady partsl delivery) She may be sedentary (I know I spent a lot of time in bed after having babies), experiencing side effects of narcotic pain meds.

It does look like she has an anxiety component -- she said she is holding her BM due to fear of pain.

The aeb/amb component is the reasons WHY you made the nursing dx you did. A colace Rx isn't evidence -- it's often included in a postpartum order set (at least in my experience as a pt and in school). It's not necessarily ordered because the pt has reported hard stools -- it's often ordered automatically because postpartum pts are at risk for constipation.

The pt's own report "I am holding my BM to lessen pain and straining" does support your dx of an constipation, however. Also, how many days ago was her last BM? If her norm is daily but hasn't gone in 4 or 5 days, that is supporting evidence. If she just had her first BM and you observed (or pt reported) a bunch of little brown rocks, that hard stool is supporting evidence.

As for other nursing dx's, we can't say without more info. What other assessment findings are there? (firm breasts and lochia are expected/normal findings -- unless lochia is excessive, say saturating a pad every hour.)

Your related to factors are specific to this pt... not irregular BMs. Constipation IS a form of irregular BM.

In this case, it *could* be r/t: decreased GI motility postop (although I'm confused... DID she have surgery? An episiotomy implies it was a lady partsl delivery) She may be sedentary (I know I spent a lot of time in bed after having babies), experiencing side effects of narcotic pain meds.

It does look like she has an anxiety component -- she said she is holding her BM due to fear of pain.

The aeb/amb component is the reasons WHY you made the nursing dx you did. A colace Rx isn't evidence -- it's often included in a postpartum order set (at least in my experience as a pt and in school). It's not necessarily ordered because the pt has reported hard stools -- it's often ordered automatically because postpartum pts are at risk for constipation.

The pt's own report "I am holding my BM to lessen pain and straining" does support your dx of an constipation, however. Also, how many days ago was her last BM? If her norm is daily but hasn't gone in 4 or 5 days, that is supporting evidence. If she just had her first BM and you observed (or pt reported) a bunch of little brown rocks, that hard stool is supporting evidence.

As for other nursing dx's, we can't say without more info. What other assessment findings are there? (firm breasts and lochia are expected/normal findings -- unless lochia is excessive, say saturating a pad every hour.)

I agree with Here.I.Stand. You need to use your ASSESSMENT findings as your AMB/AEB. Your assessment findings are your evidence to support the nursing diagnosis (in this case constipation). Assessment findings are not doctor's orders, prescriptions, etc. As Here.I.Stand stated, if your pt usually has a BM once a day and has not had a BM in 4 or 5 days, then you would use that as AMB (e.g., "AMB pt usually has BM once a day but has not had a BM in 4 days."); or if pt had a BM but you observed or the pt reported that it only consisted of little brown rocks, then you use that as AMB (e.g., "AMB pt reported (or nurse observed) hard stool appearing at little brown rocks/pebbles (whatever description fits)."). You need to look at what YOU OBSERVED IN YOUR ASSESSMENT or what the PT REPORTED IN YOUR ASSESSMENT. Not focus on what was ordered, what the pts medical diagnoses are, etc.