A nursing diagnosis represents a clinical judgment made by a professional nurse concerning an individual’s or family’s responses to health problems or life processes. This judgment guides the nurse in selecting appropriate interventions to achieve patient-specific outcomes. Unlike a broad medical term, a nursing diagnosis focuses on the human experience of a condition, providing a framework for independent nursing actions. The process begins with a thorough assessment to determine if a physical issue, such as difficulty with bowel movements, fits into this professional classification system.
Constipation as a Formal Nursing Diagnosis
Constipation is a classified nursing diagnosis. The North American Nursing Diagnosis Association – International (NANDA-I) includes it within its standardized terminology, which is used globally by nurses to communicate patient needs clearly. This specific classification allows nurses to identify, treat, and manage the patient’s experience related to infrequent or difficult stool evacuation.
The NANDA-I definition describes Constipation as a decrease in the normal frequency of defecation, often accompanied by the difficult or incomplete passage of stool, or the passage of excessively hard, dry stool. This classification is used when the problem is currently present and requires immediate intervention. A related diagnosis, “Risk for Constipation,” is also recognized, which applies to individuals with a higher vulnerability to developing the problem due to various contributing factors.
Managing the physical and psychological impact of Constipation falls within the professional scope of nursing practice. Nurses use this precise language to ensure consistent documentation and continuity of care across different healthcare settings.
Distinguishing Nursing Diagnosis From Medical Diagnosis
The distinction between a nursing diagnosis and a medical diagnosis represents a difference in focus and scope of practice. A medical diagnosis identifies a specific disease, pathology, or injury, aiming to pinpoint the underlying cause of a health condition. For example, a medical diagnosis might be Irritable Bowel Syndrome, diverticulitis, or bowel obstruction, which require a physician’s determination and prescription for treatment.
The medical diagnosis remains constant as long as the disease is present, regardless of the patient’s day-to-day symptoms or responses. In contrast, a nursing diagnosis identifies the human response to that medical condition or life process, focusing on the patient’s immediate needs and ability to function. The nursing diagnosis is dynamic, changing as the patient’s response evolves or improves.
To illustrate, a patient may have the medical diagnosis of Parkinson’s Disease, a chronic neurological condition that affects movement. However, the nursing diagnoses for this patient might include “Impaired Physical Mobility” related to muscle rigidity, “Risk for Falls” related to gait changes, and “Constipation” related to decreased gastrointestinal motility caused by the disease and some medications.
The nurse addresses the human response, such as the difficulty passing stool, through independent interventions, while the physician treats the underlying disease. The nurse can implement actions like dietary modifications, ambulation schedules, and administering prescribed laxatives to manage the constipation. This focus on the patient’s response empowers the nurse to create a personalized care plan aimed at improving immediate comfort and daily functioning.
Validating the Nursing Diagnosis
For a nurse to formally assign the diagnosis of Constipation, a systematic assessment process must be undertaken to validate its presence. This process involves gathering specific pieces of evidence, known as defining characteristics and related factors, which confirm the patient’s current state. Defining characteristics are the observable signs and symptoms that the patient is experiencing.
These characteristics can be subjective, meaning they are reported by the patient, such as straining during defecation, the sensation of incomplete evacuation, or reports of abdominal discomfort and cramping. Objective characteristics are those that can be measured or observed by the nurse, including infrequent bowel movements—typically fewer than three per week—the presence of hard, formed stools, or hypoactive bowel sounds on auscultation. The presence of a cluster of these signs validates the problem-focused diagnosis.
The nurse must also identify the related factors, or etiology, which are the causes or contributing factors maintaining the constipation. Common related factors include inadequate fluid intake, low dietary fiber, decreased physical activity or immobility, and medication side effects, such as those from opioid pain relievers.
By linking the problem (Constipation) to its cause (e.g., related to inadequate fluid intake) and the evidence (as evidenced by hard, dry stools and straining), the nurse formulates a complete diagnostic statement. This format ensures that the care plan is directly targeted at the modifiable factors causing the patient’s current difficulty, keeping the nurse’s focus within their scope of practice.
Care Planning and Interventions
Once the nursing diagnosis of Constipation is validated, the next step is to create a care plan focused on resolving the issue and preventing recurrence. This planning begins with establishing measurable, patient-centered goals that serve as the benchmarks for successful care. A typical goal might be, “The patient will pass soft, formed stool every one to three days by the end of the week without excessive straining.”
The nurse then implements specific interventions designed to address the identified related factors. Actions within the nursing scope of practice include patient education on increasing fluid intake, aiming for around 1.5 to 2 liters daily, and encouraging the consumption of high-fiber foods to add bulk to the stool. Physical activity is also a primary intervention, as ambulation and movement stimulate peristalsis, the muscular contractions that move waste through the intestines.
Other interventions involve monitoring and managing the patient’s output and comfort. This includes tracking the frequency and consistency of stools, assessing abdominal distension, and administering prescribed stool softeners or laxatives as needed. The nurse’s role is to coordinate these actions, ensuring that the patient’s immediate needs are met and that they are educated on lifestyle changes to maintain healthy bowel function after discharge.