Nursing Care Plan


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Medical Diagnoses: Constipation, mental confusion, insufficient physical activity, decreased motility of gastrointestinal tract

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

     

She has not had a bowel movement in 6 days; she has reported some transient nausea

     

     

     

     

     

Objective

her bowel sounds are hypoactive and Dorothy has paralysis on her right side with decreased grips and reflexes on the left side.

Her NGT is intact to the left nare. It is currently clamped.

Dorothy has no urinary output documented for the past 10 hours.

Intake includes 1100 ml of IV fluids and 3 cups of ice chips (~160 ml)

Temp 101.0 orally

BP 145/86

HR 110; Rhythm Afib

     


Problem

    

Constipation

    

    

    

    

    

Long Term:

Client will maintain passage of soft, formed stool every 1 to 3 days without straining by the time of discharge.

Encourage a fluid intake of 1.5 to 2 L/day (six to eight glasses of liquids per day), unless contraindicated because of renal insufficiency. Cereal fibers such as wheat bran add additional bulk by attracting water to the fiber, so adequate fluid intake is essential. Increasing fluid intake to 1.5 to 2 L/day while maintaining a fiber intake of 25 g can significantly increase the frequency of stools in clients with constipation (Weeks, Hubbartt & Michaels, 2000; Anti, 1998). EB: Increasing fluid intake is not helpful if the person is already well hydrated

Provide laxatives, suppositories, and enemas only as needed if other more natural interventions are not effective, and as ordered only; establish a client goal of eliminating their use. Use of stimulant laxatives should be avoided because they result in laxative dependence and loss of normal bowel function (Merli & Graham, 2003). Laxatives and enemas also damage the surface epithelium of the colon (Schmelzer et al, 2004).

Encourage client to resume walking and activities of daily living as soon as possible if their mobility has been restricted. Encourage turning and changing positions in bed, lifting the hips off the bed, performing range-of-motion exercises, alternately lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching the arms away from the body, and pulling in the abdomen while taking deep breaths. Bed rest and decreased mobility lead to constipation, but additional exercise does not help the constipated person who is already mobile. When the client has diminished mobility, even minimal activity increases peristalsis, which is necessary to prevent constipation (Weeks, Hubbartt & Michaels, 2000). EB: Twelve weeks of physical activity significantly decreased symptoms of constipation and difficulty defecating in sedentary clients with chronic constipation, but transit time decreased only in subjects who had abnormally long transit time before starting the exercise program (DeSchryver et al, 2005).

    

    

     


     

R/T

mental confusion

insufficient physical activity

neurological impairment

decreased motility of gastrointestinal tract

 

  

    

    

    

    

    

Short Term:

Client will Identify measures that prevent or treat constipation by the end of shift on 04.07.09 at 1300.

Teach client to consume a fiber intake of 20 g/day (for adults), ensuring that the fiber is palatable to the individual and that fluid intake is adequate. Add fiber gradually to decrease bloating and flatus. Larger stools move through the colon faster than smaller stools, and dietary fiber makes stools bigger because it is undigested in the upper intestinal tract. Fiber fermentation by bacteria in the colon produces gas. EB: Analysis of survey data from a subset of women (N 62,036) in the Nurses' Health Study Women found that those with a median fiber intake of 20 g/day were less likely to experience constipation than those with a median intake of 7 g/day (Dukas, Willett & Giovannucci, 2003). EBN: A study protocol that included high-fiber foods that had been tested for palatability and 1500 ml of fluid daily reduced constipation from 59 to 9; reduced laxative use from 59 to 8; and eliminated impactions in a group of hospitalized, immobilized, vascular clients (Hall et al, 1995). EB: Researchers found that rye bread shortened intestinal transit time, softened the feces, and eased defecation of 59 women with constipation, and that yogurt lessened the bloating and flatulence resulting from rye bread (Hongisto et al, 2006).

 

Teach client to use a mixture of bran cereal, applesauce, and prune juice; begin administration in small amounts and gradually increase amount. Keep refrigerated. Always check with the primary care practitioner before initiating this intervention. It is important that the client also ingest sufficient fluids. EBN: This bran mixture has been shown to be effective even with short-term use in elderly clients recovering from acute conditions. Note: Giving fiber without sufficient fluid has resulted in worsening of constipation (Muller-Lissner et al, 2005). Additional Research: (Howard, West & Ossip-Klein, 2000, Gibson et al, 1995; Beverley & Travis, 1992; Neal, 1995).

If not contraindicated, teach the client how to do bent-leg sit-ups to increase abdominal tone; also encourage the client to contract the abdominal muscles frequently throughout the day. Help the client develop a daily exercise program to increase peristalsis.

    

    

    

    

AEB

No bowel movement in the past six days.

    

    

    

    

    

    

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References:

 

DeSchryver AM, Keulemans YC, Peters HP et al: Effects of regular physical activity on defecation pattern in middle-aged patients complaining of chronic constipation, Scan J Gastroenterol 40:422429, 2005.

Dukas L, Willett WC, Giovannucci EL: Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women, Am Gastroenterol 98(8):17901796, 2003.

Hall GR, Karstens M, Rakel B et al: Managing constipation using a research-based protocol, Medsurg Nursing 4(1):1120, 1995.

Hongisto SM, Paajanen L, Saxelin M et al: A combination of fibre-rich rye bread and yoghurt containing Lactobacillus GG improves bowel function in women with self-reported constipation, Eur J Clin Nutr 60:319324, 2006.

 

Howard LV, West D, Ossip-Klein DJ: Chronic constipation management for institutionalized older adults, Geriatr Nurs 21(2):78, 2000.

 

Merli GJ, Graham MG: Three steps to better management of constipation, Patient Care 37:6, 2003.

 

Muller-Lissner SA, Kamm MA, Scarpignato C et al: Myths and misconceptions about constipation, AM J Gastroenterol 100(1):232242, 2005.

Schmelzer M, Case P, Chappell SM et al: Colonic cleansing, fluid absorption, and discomfort following tap water and soapsuds enemas, Appl Nurs Res 13(2):83, 2000.

Weeks SK, Hubbartt E, Michaels TK: Keys to bowel success, Rehabil Nurs 25(2):66, 2000.



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