- Acute Pain related to Constipation and Inability to pass gas and/or stool as evidenced by
Moaning, crying, restlessness and Abdominal tenderness - Constipation related to Decreased motility of gastrointestinal tract and
Electrolyte imbalance as evidenced by Abdominal distention and Inability to pass stool - Dysfunctional Gastrointestinal Motility related to Inflammatory process and Electrolyte imbalance and as evidenced by Abdominal distension and Sluggish bowel sounds
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain related to Constipation and Inability to pass gas and/or stool as evidenced by Moaning, crying, restlessness and Abdominal tenderness | Patient will report alleviation or control of pain. Patient will describe satisfactory pain control at a level less than 4 on the pain scale. Patient will display comfort, as evidenced by resting and unlabored breathing. | 1. Provide a quiet and relaxing environment. Some patients may perceive pain as worse when stressors are present in the environment. Providing a relaxed atmosphere will be conducive to alleviating pain. 2. Insert an NG tube. This intervention will not prevent or shorten the duration of an ileus but can provide some relief from decompression once an ileus has occurred. 3. Administer NSAIDs over opioids. Opioids are a significant cause of ileus following abdominal surgery. NSAIDs may assist in reducing the amount and duration of opioids needed to control pain. 4. Provide nonpharmacologic relief. Paralytic ileus often resolves in a few days. Provide relief interventions through distraction, relaxation, and rest. | Patient reported alleviation or control of pain. Patient described satisfactory pain control at a level less than 4 on the pain scale. Patient displayed comfort, as evidenced by resting and unlaboured breathing. |
| Subjective data: -Less than three bowel movements per week -Hard, dry stool -Lumpy stool -Difficulty/straining to pass stool, painful -Sensation of feeling bloated or nauseous Objective Data: -Assess stool characteristics per patient Color, consistency, amount -Use appropriate tools as needed (Bristol Stool Chart) | Constipation related to Decreased motility of gastrointestinal tract and Electrolyte imbalance as evidenced by Abdominal distention and Inability to pass stool | Patient will have a regular bowel movement. Patient will verbalize reduced abdominal pain and bloating. Patient will display an increase in activity level. | 1. Instruct on bowel rest. The patient may need to be restricted from eating anything by mouth to help the intestines rest until bowel sounds return or flatus is passed. 2. Administer parenteral nutrition. The replacement of fluids, electrolytes, and nutrition can quickly hasten recovery. 3. Encourage increased activity within individual limits. Mobilization helps stimulate intestinal peristalsis. 4. Administer prokinetics as prescribed. Prokinetic drugs such as metoclopramide, cisapride or erythromycin may enhance gastrointestinal motility by increasing the frequency or strength of contractions. | Patient has regular bowel movement. Patient verbalized reduced abdominal pain and bloating. Patient displayed an increase in activity level. |
| Subjective Data: Verbalizes Abdominal discomfort Objective Data: -Abdominal distension -Abdominal discomfort -Constipation -Nausea -Vomiting -Sluggish bowel sounds -Absence of flatus | Dysfunctional Gastrointestinal Motility related to Inflammatory process and Electrolyte imbalance and as evidenced by Abdominal distension and Sluggish bowel sounds | Patient will not experience abdominal distension or discomfort following abdominal surgery. Patient will have at least one bowel movement every three days. | 1. Keep the patient NPO as ordered. Patients with paralytic ileus are kept NPO until the return of bowel sounds or flatus. This allows the bowel to rest and recover and prevents worsening complications. 2. Administer fluid and electrolyte replacement. Fluid and electrolyte replacement can help prevent dehydration and electrolyte imbalances, which hastens the return of peristalsis in patients with paralytic ileus. 3. Administer medications as indicated. Prokinetic drugs like metoclopramide are prescribed to stimulate peristalsis, improve gastrointestinal motility, and resolve nausea and vomiting. 4. Insert a nasogastric tube as indicated. An NG tube may be indicated for patients with severe cases of paralytic ileus to decompress the gastrointestinal tract and relieve distension. 5. Assist the patient in ambulation. Ambulation can help increase gastrointestinal motility and resolve paralytic ileus and its associated symptoms like bloating. | Patient relieved from abdominal distension or discomfort following abdominal surgery. Patient had at least one bowel movement every three days. |