there is information and a number of posts on how to construct a care plan on this thread: http://allnurses.com/general-nursing...ns-286986.html
- help with care plans
which you should also look at.
a care plan is all about determining what your patient's nursing problems are and then listing strategies to do something about them. interventions are the strategies for the problems. nursing diagnoses are merely the names we attach to the nursing problems. although you entitled your post "interventions for constipation r/t pain medication and immobility" it sounds as if you are asking for help in identifying what this person's nursing diagnoses (nursing problems) are.
problem solving is what you are in nursing school to learn and the nursing process is the tool you are expected to use to do it. it adapts very well to care planning and if you get into the habit of using the steps of the nursing process to care plan as a student it will serve you well in many, many unexpected ways. i will show you how the nursing process works for care planning based on the information you posted.
step #1 assessment.
before any decisions are made about anything you must do some investigation and data collection. assessment consists of:
step #2 determination of the patient's problem(s)/nursing diagnosis part 1
- a health history (review of systems) - all you've told us is that he has fractured his hip and had surgery. what kind of hip surgery? a pinning or a hip replacement? the post op care is slightly different for each. we also know that he had throat cancer. i've had an oral cancer and i have post treatment complications, so i'm guessing he probably has some specific to this cancer as well. what are they?
- performing a physical exam - there really is no physical exam data presented. data that is useful for the care planning is that he has had no bowel movement in 4 days and that he is not very mobile. not being very mobile should be more specified. he has also said, "i just don't feel good, i don't want anything to eat." that would require looking at more empirical evidence of food intake, checking for recorded weights to see if he is losing weight and looking at labwork for electrolyte imbalances.
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - if he is not very mobile and he has an impaired hip, how is he accomplishing his adls? how does his bath get done daily? does he do it all by himself? any activity that requires someone to help him is a self-care deficit.
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - how did this fracture happen in the first place? did he fall or was it a pathological fracture as a result of metastatic cancer? that's important to know because there is a nursing problem there that needs to be addressed so the other hip is protected from a similar fate. we also need to be aware of the complications that can occur for the specific type of surgery that he had on this hip. you should be able to find the specific hip surgery he had on this website and it will tell you about the surgery and list any complications:
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - pain medication is a medical treatment and constipation is a complication of most opioids. a peg tube is a medical treatment. as nurses we are often tasked to carry out the maintenance and care of them. what other medications is he taking? they can sometimes be clues about other medical problems a patient has that they have forgotten to tell us. i can't rattle off my list of medications and i have to rely on a written list.
- this starts by going through the data collected above and pulling out and making a list of the abnormal assessment data. why? because normal means there isn't a problem. abnormal is pointing a way toward something being out of order and that is going to help you identify a problem. since this is a post-op patient we have to consider the complications of general anesthesia even if it has been several days.
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism) (these can manifest at any time)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity (very important to this patient, particularly in the unaffected leg)
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection) (very important to this patient)
- fluid and electrolyte imbalances
- urinary retention
- constipation (patient already has)
- surgical pain (patient already has)
- nausea/vomiting (paralytic ileus)
and then you have:
- no bowel movement in 4 days
- not very mobile
- "i just don't feel good, i don't want anything to eat."
i would like to know:
- the reason for the fracture of the hip
from this data we find our nursing problems and attach the name to them. nanda has taken the trouble to give us guidelines for each nursing diagnosis: its definition, related factors (likely causes) and defining characteristics (signs and symptoms). if you have access to a taxonomy, that's what this guideline is called (it is printed in the appendix of recent editions of taber's cyclopedic medical dictionary
), you look for nursing diagnoses to match with the data listed above.
step #3 planning
- constipation r/t effect of opioids aeb no bowel movement in 4 days
- impaired physical mobility r/t surgical incision aeb not very mobile
- self-care deficits r/t musculoskeltal impairment
- acute pain r/t surgical intervention
- impaired tissue integrity r/t surgical intervention
- risk for ineffective airway clearance r/t effects of anesthesia
- risk for imbalanced nutrition: less than body requirements
- risk for infection r/t invasive procedure
- risk for falls or ineffective protection (in regard to reason for fractured hip)
- this is where you write measurable goals/outcomes and nursing interventions. they are based on the data used to identify the nursing problems. back in the "old days" before nursing diagnoses we used to just write this data, or the symptoms, patients had on the care plan in the column where it said "nursing problem". the next column was for the nursing actions, or interventions. you are doing the same thing today except that the data is often grouped and a label (the nursing diagnosis) has been placed on it. but, your interventions are aimed at those symptoms that made you choose that diagnosis to begin with which is why your assessment information is so important. your diagnostic statement even refers to them as "evidence".
so, since you asked about constipation
, here is how we continue the nursing process for this problem. your evidence is that the patient has had no bm for 4 days. then, nursing interventions can be classified into 4 types:
- assess/monitor/evaluate/observe (to evaluate the patient's condition)
- assess abdomen for abdominal distension, pain, cramping and/or absence of bowel sounds. (you are assessing for paralytic ileus, a complication of anesthesia)
- care/perform/provide/assist (performing actual patient care)
- encourage the patient to ambulate and move as much as possible.
- encourage fluid intake, especially warm fluids and any fluid that contains fiber.
- encourage the patient to eat fresh fruits and vegetables.
- assist to bedside commode after a meal to attempt a bm.
- administer stool softener, laxative, suppository or enema as ordered.
- teach/educate/instruct/supervise (educating patient or caregiver)
- teach patient that consuming fiber (bulk and roughage) helps to move stool through the bowels.
- teach patient that physical activity will help stimulate gi functioning.
- manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
- notify physician and request order for enema/order for fiber intake via a pill.
- consult with dietician.
you will do this as best you can for each piece of evidence you have for each of your nursing diagnoses. each one of your interventions is a nursing order. just as a doctor writes his physician's orders we write nursing orders. is this process making some sense?