Care Plan Feedback

[littley]

ok well, my professor buckled down for about 2 weeks, gave us feedback on only 2 careplans and has since then been back to her lax self again. so, within the next couple days i'll be posting up some scenarios with the careplan i came up with and would really appreciate some feedback. the purpose is not prioritizing but coming up with a dx and appropriate goals and interventions. this is not for a grade...these are practice scenarios so any type feedback can be taken. the scenario goes as follows:

mr. ch is a 65 y/o admitted to the medical unit from a rehab center with severe abdominal pain (9). past med hx of open heart surgery 6 months ago and a cva 2 months after surgery with left sided weakness. on examination, abdomen is firm to touch with tenderness on palpation. mr ch complains of difficulty swallowing, is very selective with food choice ,and takes minimal oral fluids .mr. ch refuses to get out of bed and has not had a bowel movement for 4 days. dr orders include: plavix 75 mg po daily

what would be assessed?: assess vital signs, assess the abdomen (ausculate, percuss, and palpate), assess rom, assess diet history and eating habits, asses usual patter of bowel elimination.

nursing dx: constipation r/t immobility and insufficient fluid intake aeb subj: abd pain of 9 on a 10 scale, refuses to get out of bed, difficulty swallowing; obj: left sided weakness, minimal oral fluids, no bowel mvment for 4 days, firm abdomen, tenderness on palpation.

short term goal: the patient will report a decrease in abdominal pain from constipation from a 9 to 0-3 within 2 hours.

long term goal: the patient will have a bowel movement within the next 24 hours.

interventions:

1. the nurse will assess the patient's usual defecation patterns and diet history.

rationale: this will allow the nurse to become familiar with the patients bowel patterns and usual diet for more personalized plan of care

2. the nurse will assess the patient's bowel sounds.

rationale: patient may be impacted since there has been no bowel movement within 4 days and abdominal pain is severe. hypoactive bowel sounds may indicate impactation.

3. the nurse will inform physician of any abnormal findings.

rationale: will allow the physcian to review orders and change them if needed for patient's condition.

4.the nurse will show the patient how to use the call light and place it within reach.

rationale: patient can call nurse as soon as urge to defecate presents for assistance and will provide patient safety due to hemiplegia.

5. the nurse will assist the patient in ambulating to the bathroom when urge presents and assist the patient with leaning forward at 90 degrees when defecating.

rationale: flexion decreases the resistance to the movement of feces from the rectum.

6. the nurse will encourage the client to walk and change positions frequently.

rationale: bed rest and decreased mobility lead to constipation. mobility increases peristalsis.

7. the nurse will administer plavix per dr orders.

rationale: patient has a hx of cva so anti-coagulant therapy needs to be given as dr ordered.

8. the nurse will consult with the physician for a nutrition referral to provide patient with adequate fiber intake.

rationale: 20g/day of fiber will increase bulk which cause stool to move through the colon faster.

9. the nurse will consult with the physician to recommend an order for an enema.

rationale: patient has had no bowel movement for 4 days and has severe abdominal pain. enema will alleviate symptoms of constipation and alleviate pain without having to administer pain meds, which may cause worsening of constipation.

10. the nurse will provide patient with 1500-2000ml of fluids daily and encourage patient to drink it all.

rationale: hydration will increase water in the intestines, aiding in the softening and passage of stool. adequate water intake is also essential with a high fiber diet.

11. the nurse will teach the patient the importance of adequate fiber and fluid intake and physical activity in maintaining a proper defecation pattern.

rationale: an informed patient is more likely to follow through on treatment.

12. the nurse will teach the patient the risks of impactation and its consequences.

rationale: same as above

13. the nurse will teach the patient how to avoid the vasalva maneuver and why.

rationale: the maneuver can cause bradycardia and consequently maybe even death in cardiac patients.

thanks in advance for feedback; its greatly appreciated!!!

[truern]

You have some *great* interventions for constipation, but I'm wondering why you'd assume no BMX4 days would lead to a NINE on the pain scale? Many people don't have daily BMs.

Just curious :)

But still...GREAT interventions and rationales :)

[Daytonite, BSN, RN]

when you get these scenarios, take the information and list it out. to diagnose you need the abnormal data and that is contained in the scenario. use and follow the steps of the nursing process to problem solve and care plan this.

step 1 assessment - if this were a real patient there are a number of things you would do. the abnormal data has already been listed for you. for learning purposes, however, (because you are a learner) you need to

• review the pathophysiology, signs and symptoms and complications of their medical condition - the scenario tells you this patient had a cva (stroke) 4 months ago and open heart surgery 6 months ago. stroke is a complication of many different types of surgery.
  
• review the signs, symptoms and side effects of the medications they are taking - look up plavix, why it is given and what its side effects are - one of the side effects of this drug is gi bleeding.
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - diagnoses must have evidence to support them and the abnormal data is that evidence. this is the abnormal data from the scenario grouped by importance and function:

• severe abdominal pain (9) - this means the pain is 9 on a scale of 0 to 10
  
• abdomen is firm to touch with tenderness on palpation
  
• has not had a bowel movement for 4 days
  
• takes minimal oral fluids
  
• difficulty swallowing
  
• selective with food choice
  
• refuses to get out of bed
  
• left sided weakness
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. see http://www.merck.com/mmpe/sec02/ch011/ch011b.html. using the data and a nursing diagnosis reference if you need in order to become familiar with the various nursing diagnoses, their definitions, related factors and defining characteristics, you might come up with these diagnoses--or something else.

• acute pain r/t unknown abdominal process aeb abdominal pain of 9 on a 0 to 10 scale and tenderness upon palpation.
  
• impaired swallowing r/t neuromuscular dysfunction secondary to cva aeb difficulty swallowing
  
• impaired physical mobility r/t neuromuscular impairment secondary to cva aeb left sided weakness
  
• risk for deficient fluid volume r/t inadequate fluid intake
  
• risk for injury r/t untoward effect of plavix
  
• risk for impaired skin integrity r/t immobility and refusal to get out of bed
  

i am not diagnosing constipation because i think the doctor would have ordered something for the "no bm for 4 days" if he felt it significant. this patient was admitted for severe abdominal pain. he will be worked up by the doctor for an acute abdomen.

-----------------------------------------

what would be assessed?: assess vital signs, assess the abdomen (ausculate, percuss, and palpate), assess rom, assess diet history and eating habits, asses usual patter of bowel elimination.

nursing dx: constipation r/t immobility and insufficient fluid intake aeb subj: abd pain of 9 on a 10 scale, refuses to get out of bed, difficulty swallowing; obj: left sided weakness, minimal oral fluids, no bowel mvment for 4 days, firm abdomen, tenderness on palpation.

short term goal: the patient will report a decrease in abdominal pain from constipation from a 9 to 0-3 within 2 hours.

for a true constipation problem, we would get him cleaned out within a few hours.

long term goal: the patient will have a bowel movement within the next 24 hours.

in 24 hours, he would be on a stool softener and a high fiber diet. his impaction would have been cleared out within a few hours of admission or we would have been working on it.

interventions:

1. the nurse will assess the patient's usual defecation patterns and diet history.

rationale: this will allow the nurse to become familiar with the patients bowel patterns and usual diet for more personalized plan of care

2. the nurse will assess the patient's bowel sounds.

rationale: patient may be impacted since there has been no bowel movement within 4 days and abdominal pain is severe. hypoactive bowel sounds may indicate impactation.

impaction can only be assessed by doing a digital (manual) exam of the rectum.

3. the nurse will inform physician of any abnormal findings.

rationale: will allow the physcian to review orders and change them if needed for patient's condition.

4.the nurse will show the patient how to use the call light and place it within reach.

rationale: patient can call nurse as soon as urge to defecate presents for assistance and will provide patient safety due to hemiplegia.

5. the nurse will assist the patient in ambulating to the bathroom when urge presents and assist the patient with leaning forward at 90 degrees when defecating.

rationale: flexion decreases the resistance to the movement of feces from the rectum.

can you really lean forward 90 degrees when sitting? you'd be folded in half.

6. the nurse will encourage the client to walk and change positions frequently.

rationale: bed rest and decreased mobility lead to constipation. mobility increases peristalsis.

7. the nurse will administer plavix per dr orders.

rationale: patient has a hx of cva so anti-coagulant therapy needs to be given as dr ordered.

what does giving plavix have to do with having a bowel movement? this makes no sense anddoesn't need to be here.

8. the nurse will consult with the physician for a nutrition referral to provide patient with adequate fiber intake.

rationale: 20g/day of fiber will increase bulk which cause stool to move through the colon faster.

9. the nurse will consult with the physician to recommend an order for an enema.

rationale: patient has had no bowel movement for 4 days and has severe abdominal pain. enema will alleviate symptoms of constipation and alleviate pain without having to administer pain meds, which may cause worsening of constipation.

10. the nurse will provide patient with 1500-2000ml of fluids daily and encourage patient to drink it all.

rationale: hydration will increase water in the intestines, aiding in the softening and passage of stool. adequate water intake is also essential with a high fiber diet.

11. the nurse will teach the patient the importance of adequate fiber and fluid intake and physical activity in maintaining a proper defecation pattern.

rationale: an informed patient is more likely to follow through on treatment.

12. the nurse will teach the patient the risks of impactation and its consequences.

rationale: same as above

13. the nurse will teach the patient how to avoid the vasalva maneuver and why.

rationale: the maneuver can cause bradycardia and consequently maybe even death in cardiac patients.

[Daytonite, BSN, RN]

Acute Pain R/T unknown abdominal process AEB abdominal pain of 9 on a 0 to 10 scale and tenderness upon palpation

• Goal: Patient will have pain reduced to 4 of a scale of 0 to 10 30 minutes after receiving pain medication.
  
• Interventions:
  
  • Assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
    
  • Assess and document where in the abdomen the pain is located and what, if anything, makes it worse or better
    
  • Observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
    
  • Give pain medication as ordered
    
  • Provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
    
  • Reposition the patient
    
  • Give a back massage
    
  • Use short, simple relaxation exercises to distract the patient's attention
    
  • Dim the lights in the room and keep noise down
    
  • Play soft, soothing music
    
  • Have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
    
  • Reassess and evaluate the patient's response to each method employed. Ask the patient which techniques work better for them.
    
  • Monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
    

[aerorunner80, ADN, BSN, MSN, APRN]

Another independent nursing intervention you can do is offer prune juice or prunes.

I did this for a pt this morning and they had a normal soft formed bm within the hour. They were constipated before will all the classic s/s (distended, hard abdomen, report of "rock like" stool, no bm for 5 days)

ETA: they did have slightly hyeperactive bowel sounds as well