Care Plan for Constipation Management

Category / Primary Body System

• Gastrointestinal System

Problem

• Potential for constipation related to decreased mobility.

Goal

• Resident will not exhibit any signs of constipation for the next 90 days.

Plan/Approach

1. Monitoring and Assessment

   • Monitor if the resident has a bowel movement daily and document the frequency, consistency, and ease of bowel movements.
   • Monitor for abdominal distention and report any findings.
   • Monitor for decreased appetite and report any changes.
   • Monitor for nausea, vomiting, and other signs of gastrointestinal discomfort (NIV).

2. Medication and Bowel Regimen

   • Administer bowel medications as ordered to promote regular bowel movements.

3. Hydration and Nutrition

   • Encourage fluid intake to help soften stool and promote regular bowel movements.

4. Communication and Reporting

   • Update MD/NP as ordered about the resident’s bowel habits and any signs of constipation.

Rationale

1. Monitoring and Assessment

   • Regular monitoring helps detect early signs of constipation and allows for prompt intervention to prevent complications.

2. Medication and Bowel Regimen

   • Administering bowel medications as prescribed helps maintain regular bowel movements and prevent constipation.

3. Hydration and Nutrition

   • Adequate fluid intake is essential for softening stool and promoting healthy bowel function.

4. Communication and Reporting

   • Keeping the healthcare provider informed ensures that any necessary adjustments to the care plan can be made promptly.

Actions

1. Monitoring and Assessment

   • Record bowel movements daily, noting frequency, consistency, and any difficulties.
   • Assess the abdomen for distention regularly, documenting any findings.
   • Monitor for changes in appetite, noting any decrease and reporting to the healthcare provider.
   • Observe for signs of nausea, vomiting, or other gastrointestinal discomfort, and document these symptoms.

2. Medication and Bowel Regimen

   • Administer prescribed bowel medications according to the schedule, monitoring for effectiveness and any side effects.
   • Adjust the bowel regimen as needed in consultation with the healthcare provider.

3. Hydration and Nutrition

   • Encourage the resident to drink fluids regularly, aiming for at least 8 glasses of water per day, unless contraindicated.
   • Provide foods high in fiber, such as fruits, vegetables, and whole grains, to promote regular bowel movements.

4. Communication and Reporting

   • Notify the MD/NP of any signs of constipation, changes in bowel habits, or symptoms of gastrointestinal discomfort.
   • Document all findings and interventions in the resident’s medical record.