gemini61

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.

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

P/T is a 42 year old woman who just gave birth and underwent episiotomy. She is having a constipation and irregular bowel movement. I know that anesthesia has this side effect. P/T did mention that she is holding on her b/m to lessen pain and strain with her surgery.. Can you help me construct a three-part statement for this diagnosis? The p/t had Lochta Serosa and breasts are firm but may not breastfeed effectively because of her surgery. I need 2 more Diagnosis? Can somebody help? Thanks

I am at a loss in starting my case plan. I was assigned to a post natal 42 year old woman who delivered on full term lady partslly with episiotomy. She was rushed to the hospital due to abdominal pain due to contraction occurring at close intervals. Diabetes runs in her family and has a history of anemia. I was asked to observe for 1 day and has a very limited information of the patient. She is suffering from constipation and taking Colace for stool softening. I need help on History of Present Illness. What do I have to include in the HPI? I do not have a complete list of medications in her MAR. What diagnosis should I include? Help!