Nursing Care Plan

 


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Medical Diagnoses:  Constipation, arteriosclerotic cardiovascular disease, hypothyroidism, seizure disorder, osteoarthritis, mixed incontinence, congestive heart failure, hypertension, depression, hx bladder cancer, depression, hyperlipidemia, thrombocytopenia, peripheral vascular disease

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:  Client reported, “My back hurts really badly.  I’ve been trying to move my bowels all day and I can’t.  I’m really uncomfortable.”

         

         

Objective:  Client has not had a bowel movement today.


Problem:  Constipation

      

      

      

      

      

      

      

Long Term:  Client will maintain passage of soft, formed stool every 1-3 days without straining.

         

Educate about the importance of and encourage client to maintain a fluid intake of 1.5-2 liters and eat at least 25 g of fiber a day.  Increasing fluid intake while maintaining a fiber intake of 25 g can significantly increase the frequency of stools in clients with constipation ((Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 248).

Interventions were implemented

Client was unable to have a bowel movement, further assessment required as only one day has passed. 

Educated and encouraged client to drink water and eat more fiber. 

R/T: 

Pharmocological agents and chronic dehydration.

      

      

      

      

      

      

Short Term:  Client will consume 32 oz. of water within 3 hours.

Review the client’s current medications to determine whether they are a source of the constipation.  Many medications are associated with chronic constipation including opiates, antidepressants, antispasmodics, diuretics, anticonvulsants, and antacids containing aluminum (Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 247)

 

Client consumed approximately 40 oz. of water.

Reviewed the medication list and determined that several medications the client is on can cause constipation.  They are Diltiazem, Oxycotin, Valproic Acid, Trazadone, and Metoprolol.

AEB:  client’s self-report of back pain and inability to have a bowel movement.

      

 

    

      

      

      

      

      

      

      

*I = Implementation.  Check those interventions/actions/orders that were implemented

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Describe pathophysiology of primary illnesses:  Constipation in the elderly is a common problem due to many changes that occur during the normal aging process. The large intestine has a decreased peristalsis rate causing constipation, as well has duller nerve sensations that can cause a client to miss defecation signals. The elderly tend to be on many medications that have side effects of constipation.  The size of the liver decreases, leading to decreased storage capacity and decreased ability to synthesize proteins and metabolize medications.  Coupled with this, the elderly tend to have decreased activity levels due to other conditions and normal aging processes.  Inactivity leads to a medication’s effects being prolonged.  The renal system also slows down as a normal change in aging.  Renally excreted drugs have a lengthened half-life due to a decrease GFR.  In addition, there are normal cardiovascular and neurological changes that impact the function of the GI system that can also lead to constipation.

         

Medications

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications

         

         

Acetaminophen/500 mg

Pain

Negligible with recommended dosage, rash, dark urine, or pale stools

Monitor for S&S of hepatotoxicity.

         

         

Bisacodyl/ 10 mg supp rect

         

Constipation

Cramping, nausea, diarrhea, fluid and electrolyte disturbances.

Monitor for bowel function, observe for s/s of electrolyte imbalances

         

MI Acid

         

         

Indigestion


Alkalosis

Monitor for relief, observe for s/s of metabolic imbalance

         

Milk of Magnesia

         

         

Constipation

Cramping, nausea, diarrhea, fluid and electrolyte disturbances.

Monitor for bowel function, observe for s/s of electrolyte imbalances

         

Nitroglycerin

         

         

Chest Pain

Headache, apprehension, blurred vision, weakness, vertigo, dizziness, faintness, muscle twitching, pallor, perspiration, and cold sweat.

Monitor for changes in consciousness, assess for headache, supervise ambulation, assess for blurred vision and dry mouth, monitor for overdose symptoms.

         

Saliva Sub Solution

Dry mouth

No major Side effects

Monitor client’s Mucosal membranes to determine level of effectiveness

Metoprolol 25 mg

Hypertension

Erythematous rash, fever, headache, muscle aches, sore throat, laryngospasm, respiratory distress, dizziness, bradycardia, fatigue, Raynaud’s phenomena, nausea, heartburn, dry mouth and mucus membranes, hypoglycemia, SOA

Monitor BP prior to administration, report significant changes, monitor I&O , daily weight, auscultate daily for pulmonary rales, withdraw drug if patient manifests mental depression; can progress into catatonia.

Aspirin EC 81mg

Platelet aggregation inhibition

Nausea, vomiting, heartburn, stomach pain, ulceration, prolonged bleeding time.

Monitor for bleeding, and stomach pain.

Citalopram/40mg

Depression

Fatigue, fever, hypotension, nausea, vomiting, abdominal pain, insomnia.

Watch for worsening depression.

Diltiazem CD 240mg

Atria fibrillation

Headache, fatigue, dizziness, drowsiness, tremor, constipation.

Check BP and ECG. Monitor for headache, supervise ambulation.

Enulose10mg/15ml

Chronic Constipation

Flatulence, belching, abdominal cramps, pain, diarrhea

Promote fluids

Oxycotin/ 10mg

Pain

Dizziness, sedation, anorexia, constipation, hepatotoxicity, pruritis, dysuria, bleeding.

Monitor for light headedness and sedation.  Monitor for s/s of overdose.

Senna Plus/

8.6mg-50mg

Constipation

Strong cramping and gripping pains in the abdomen, electrolyte imbalance, and loss of body fluids.  Nausea, rash, swelling of the fingertips, weight loss, and dark pigmentation in the colon.

Monitor for effectiveness of bowel relief, monitor for electrolyte imbalances, n/v, and rash.

Trazodone/ 50 mg

Depression

Drowsiness, insomnia, headache, impaired memory, hypotension, chest pain.

Monitor pulse, observe patients activity level, check for hypotension.

Valproic Acid/ 250 mg

Seizures

Sedation, drowsiness, dizziness, hallucinations, emotional upset, indigestion, anorexia, abdominal cramps.

Monitor patient alertness.

Peleverus Ont

Skin break down

No major side effects

Monitor skin condition to assess for improvement.

Remeron/7.5mg

Depression

Back pain, malaise, abnormal dreams, tremor, hypertension.

Monitor for worsening depression, weight gain, and orthstatic hypotension.

Prilosec/ 40mg

GERD

Headache, dizziness, fatigue, abdominal pain.

Monitor for s/s of hypotenstion and pain.


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