Care Case Study (1)-Constipation
The RN observes Joan’s abdomen is firm and distended. The RN performs and abdominal assessment. In what sequence should RN perform it?
Inspection, auscultation, percussion, palpation
Which assessment is most important for RN to perform?
Auscultate bowel sounds- b/c of subjective data reported by Joan (bloat and nausea) and objective data (abdomen firm and distended), RN’s first concern is that Joan may have decreased peristalsis.
In assessing bowel sounds, it’s important for the nurse to perform which actions?
-Listen up to 5 minutes when auscultating bowel sounds.
-inspect first and then auscultate for bowel sounds before percussing and palpating (RN should inspect first, and then auscultate for bowel sounds before percussing and palpating. Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation)
The RN auscultates her bowel sounds and hears faint gurgling sounds after 3 min. How will nurse record finding
Hypoactive bowel sounds
While the RN is completing the assessment, Joan starts crying and laments, “I just knew something would go wrong.” How should RN respond?
Tell me what is making you feel so upset
Joan tells RN she hates hospitals because, she says, “nobody ever tells you what’s happening, and you end up with all these things going wrong.” Which response by RN will encourage continued verbalization by the client?
It sounds as if you have had another experience that did not go so well
Joan responds, “I did everything my HCP told me to do. The surgery must have failed. It was supposed to make my intestines work better!” How should RN respond?
Explain to client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved (constipation is not a poor surgical outcome. multiple factors surrounding abdominal surgery can lead to decreased peristalsis)
The RN explains to Joan that she has developed constipation, probably as the result of a number of factors. Joan has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24hrs was 1,000mL. RN explains risk factors that can contribute to constipation. Which postop medication is most likely to contribute to constipation?
Morphine sulfate, an opioid analgesic-most common adverse effect of opioid analgesics is constipation.
What impact does this fluid intake have on pt’s bowel patterns?
This inadequate fluid intake has contributed to her constipation (an adult needs 1400-2000 mL of fluid daily to prevent hardening of the stool
What other questions should nurse ask Joan?
How often do you get out of bed and walk
RN revises Joan’s plan of care to include post of constipation. Before establishing the diagnostic statement, the RN needs to complete which task?
Determine which factor is causing the problem
The RN determines that Joan’s inadequate fluid intake, decreased mobility, and opioid use are significant factors in the development of her constipation., Which nursing diagnosis should the RN include in Joan’s plan of care?
Constipation related to surgery and anesthesia
RN explains to Joan that her HCP has prescribed two meds: a one-time dose of glycerin rectal suppository and docusate sodium 100mg PO daily. RN explains it will have a laxative effect. How will RN explain the action of the laxative
Movement of the intestine will push the bowel contents out so you will have a bowel movement (laxatives stimulate peristalsis so that the bowel contents can then be expelled
RN administers the first dose of docusate sodium. This med primarily alters which aspect of client’s bowel movement?
Consistency-docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination
Before administering the rectal suppository, it is most important for the RN to perform which assessment?
Observe for the presence of rectal bleeding-administration of a rectal suppository is generally contraindicated in presence of rectal bleeding, so this assessment is the most important
When administering the rectal suppository, RN asks Joan to take several slow, deep breaths. What is the rationale for this instruction?
Relax the anal sphincter and reduce discomfort-deep breathing promotes relax of the anal sphincter, thereby reducing discomfort when the suppository is inserted
RN documents the administration of the rectal suppository in the RN’s notes. Which notation is correct?
0900. One glycerin suppository administered per rectum for constipation, as prescribed.
Which statement provides the best documentation of the outcome from the suppository administration?
1100. Client produced six 1/4 inch hard pellets of brown stool following suppository administration-documentation provides the most specific objective data related to the effectiveness of the suppository.
The next day, Joan has still not expelled add’l feces. To determine the presence of a fecal impaction, the RN prepares Joan for which prescribed procedure?
-digital rectal examination
The unlicensed assistive personnel (UAP) obtains sterile gloves and lubricant for the RN and offers to perform the procedure since the RN is busy. What action should the RN implement?
Ask UAP to assist with client positioning while the nurse performs the procedure, while teaching UAP about the correct supplies as needed- not to UAP (invasive, teach UAP not sterile-use nonsterile gloves and lubricant)
While performing the digital rectal exam, the RN recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?
Decreased pulse rate
RN notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for enema administration. What action should RN take?
Administer enema as prescribed and obtain the HCP’s signature the next day.
How should the RN respond the HCP, who sounds angry and states, “Are you questioning my prescription?” How should the RN respond to the HCP?
“I want to ensure that I transcribe this prescription correctly to avoid error.”- this assertive response teaches the HCP the purpose of repeating back verbal prescriptions.
RN administers the prescribed soap suds enema to illicit irritation to the colon to help w/constipation. During the enema, Joan begins to experience abdominal cramping. What action(s) should RN take to relieve the abdominal cramping?
-lower the enema bag (will slow or stop the flow of fluid, which should reduce or stop the client’s abdominal cramping)
-roll the clamp the clamp to stop the enema until cramping subsides (stop/slow down cramping. when cramping decreases, start enema again by slowly releasing clamp to begin flow)
Joan has moderate results from enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Joan, RN receives a report from UAP that another client is vomiting. The RN tells Joan she will return as soon as she deals with the other client’s problem. What task can the RN delegate to the UAP?
-assist the client with a bed bath and hygiene if reuired (UAP scope of practice)
-assist client who vomited with mouth care after the RN administers an antiemetic (hygiene and comfort care are both within the UAP scope)
RN assesses the client who is vomiting and acts to alleviate this problem. The RN returns to Joan’s room. Joan is interested in the amount of fluid administered via enema but doesn’t understand ML. Joan received a total volume of 725mL
3cups (30mL=1oz, 1c=8oz, 725mL/30=24oz/8=3c
RN wants Joan to increase her daily oral fluid intake to 2L of fluid for the next few days. RN advises pt to drink a minimum of how many 8oz cups of fluid daily
8-9 8oz cups of fluid daily
1 8oz c=240mL (8x30mL/oz)
2L =2,000mL, 2,000mL/240mL=8.33 c/day
the remainder of joan’s surgical recovery is uneventful. she continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Joan eats a regular diet w/no restrictions and asks the RN about foods that promote bowel regularity. She states that she really like salads. Which salad choice is best to promote bowel regularity?
fresh fruit salad w/apple and banana slices
which breakfast selection by Joan indicates that she understands teaching about dietary measures to promote bowel regularity?
OJ and oatmeal w/raisins