|
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.
|
|
|
|