Nursing Dx

Taxonomy II: Elimination—Class 2 Gastrointestinal System (00015)
[Diagnostic Division: Elimination]
Nursing Diagnosis Extension and Classification (NDEC)
Submission 1998

Definition: At risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Risk Factors
FUNCTIONAL
Irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy)
Insufficient physical activity; abdominal muscle weakness
Recent environmental changes
Habitual denial/ignoring of urge to defecate
PSYCHOLOGICAL
Emotional stress; depression; mental confusion
PHYSIOLOGICAL
Change in usual foods and eating patterns; insufficient fiber/ fluid intake, dehydration; poor eating habits
Inadequate dentition or oral hygiene
Decreased motility of gastrointestinal tract
PHARMACOLOGICAL
Phenothiazides; nonsteroidal anti-inflammatory agents; sedatives; aluminum-containing antacids; laxative overuse; iron salts; anticholinergics; antidepressants; anticonvulsants; antilipemic agents; calcium channel blockers; calcium carbonate; diuretics; sympathomimetics; opiates; bismuth salts
MECHANICAL
Hemorrhoids; pregnancy; obesity
Rectal abscess or ulcer; anal stricture; anal fissures; prolapse; rectocele
Prostate enlargement; postsurgical obstruction
Neurological impairment; megacolon (Hirschsprung’s disease); tumors
Electrolyte imbalance
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Maintain usual pattern of bowel functioning.
• Verbalize understanding of risk factors and appropriate interventions/ solutions related to individual situation.

• Demonstrate behaviors or lifestyle changes to prevent developing problem.

Actions/Interventions
NURSING PRIORITY NO. 1. To identify individual risk factors/ needs:
• Auscultate abdomen for presence, location, and characteristics of bowel sounds reflecting bowel activity.
• Discuss usual elimination pattern and use of laxatives.
• Ascertain client’s beliefs and practices about bowel elimination, such as “must have a bowel movement every day or I need an enema.”
• Determine current situation and possible impact on bowel function (e.g., surgery, use of medications affecting intestinal function, advanced age, weakness, depression, and other risk factors as listed previously).
• Evaluate current dietary and fluid intake and implications for effect on bowel function.
• Review medications (new and chronic use) for impact on/ effects of changes in bowel function.

NURSING PRIORITY NO. 2. To facilitate normal bowel function:
• Instruct in/encourage balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through the colon.
• Promote adequate fluid intake, including water and high-fiber fruit juices; suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to promote moist/soft stool.
• Encourage activity/exercise within limits of individual ability to stimulate contractions of the intestines.
• Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan).
• Administer routine stool softeners, mild stimulants, or bulkforming agents prn and/or routinely when appropriate (e.g., client taking pain medications, especially opiates, or who is inactive, immobile, or unconscious).
• Ascertain frequency, color, consistency, amount of stools. Provides a baseline for comparison, promotes recognition of changes.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination. May help reduce concerns/anxiety about situation.
• Review individual risk factors/potential problems and specific interventions.

• Review appropriate use of medications.
• Encourage client to maintain elimination diary if appropriate to help monitor bowel pattern.
• Refer to NDs Constipation; perceived Constipation.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Current bowel pattern, characteristics of stool, medications.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Individual long-term needs, noting who is responsible for actions to be taken.
• Specific referrals made.