Care Case Study (1)-Constipation – Flashcards

question
The RN observes Joan's abdomen is firm and distended. The RN performs and abdominal assessment. In what sequence should RN perform it?
answer
Inspection, auscultation, percussion, palpation
question
Which assessment is most important for RN to perform?
answer
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.
question
In assessing bowel sounds, it's important for the nurse to perform which actions?
answer
-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)
question
The RN auscultates her bowel sounds and hears faint gurgling sounds after 3 min. How will nurse record finding
answer
Hypoactive bowel sounds
question
While the RN is completing the assessment, Joan starts crying and laments, "I just knew something would go wrong." How should RN respond?
answer
Tell me what is making you feel so upset
question
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?
answer
It sounds as if you have had another experience that did not go so well
question
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?
answer
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)
question
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?
answer
Morphine sulfate, an opioid analgesic-most common adverse effect of opioid analgesics is constipation.
question
What impact does this fluid intake have on pt's bowel patterns?
answer
This inadequate fluid intake has contributed to her constipation (an adult needs 1400-2000 mL of fluid daily to prevent hardening of the stool
question
What other questions should nurse ask Joan?
answer
How often do you get out of bed and walk
question
RN revises Joan's plan of care to include post of constipation. Before establishing the diagnostic statement, the RN needs to complete which task?
answer
Determine which factor is causing the problem
question
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?
answer
Constipation related to surgery and anesthesia
question
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
answer
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
question
RN administers the first dose of docusate sodium. This med primarily alters which aspect of client's bowel movement?
answer
Consistency-docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination
question
Before administering the rectal suppository, it is most important for the RN to perform which assessment?
answer
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
question
When administering the rectal suppository, RN asks Joan to take several slow, deep breaths. What is the rationale for this instruction?
answer
Relax the anal sphincter and reduce discomfort-deep breathing promotes relax of the anal sphincter, thereby reducing discomfort when the suppository is inserted
question
RN documents the administration of the rectal suppository in the RN's notes. Which notation is correct?
answer
0900. One glycerin suppository administered per rectum for constipation, as prescribed.
question
Which statement provides the best documentation of the outcome from the suppository administration?
answer
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.
question
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?
answer
-radiographic examination -digital rectal examination
question
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?
answer
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)
question
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?
answer
Decreased pulse rate
question
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?
answer
Administer enema as prescribed and obtain the HCP's signature the next day.
question
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?
answer
"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.
question
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?
answer
-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)
question
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?
answer
-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)
question
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
answer
3cups (30mL=1oz, 1c=8oz, 725mL/30=24oz/8=3c
question
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
answer
8-9 8oz cups of fluid daily 1 8oz c=240mL (8x30mL/oz) 2L =2,000mL, 2,000mL/240mL=8.33 c/day
question
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?
answer
fresh fruit salad w/apple and banana slices
question
which breakfast selection by Joan indicates that she understands teaching about dietary measures to promote bowel regularity?
answer
OJ and oatmeal w/raisins
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question
The RN observes Joan's abdomen is firm and distended. The RN performs and abdominal assessment. In what sequence should RN perform it?
answer
Inspection, auscultation, percussion, palpation
question
Which assessment is most important for RN to perform?
answer
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.
question
In assessing bowel sounds, it's important for the nurse to perform which actions?
answer
-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)
question
The RN auscultates her bowel sounds and hears faint gurgling sounds after 3 min. How will nurse record finding
answer
Hypoactive bowel sounds
question
While the RN is completing the assessment, Joan starts crying and laments, "I just knew something would go wrong." How should RN respond?
answer
Tell me what is making you feel so upset
question
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?
answer
It sounds as if you have had another experience that did not go so well
question
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?
answer
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)
question
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?
answer
Morphine sulfate, an opioid analgesic-most common adverse effect of opioid analgesics is constipation.
question
What impact does this fluid intake have on pt's bowel patterns?
answer
This inadequate fluid intake has contributed to her constipation (an adult needs 1400-2000 mL of fluid daily to prevent hardening of the stool
question
What other questions should nurse ask Joan?
answer
How often do you get out of bed and walk
question
RN revises Joan's plan of care to include post of constipation. Before establishing the diagnostic statement, the RN needs to complete which task?
answer
Determine which factor is causing the problem
question
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?
answer
Constipation related to surgery and anesthesia
question
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
answer
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
question
RN administers the first dose of docusate sodium. This med primarily alters which aspect of client's bowel movement?
answer
Consistency-docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination
question
Before administering the rectal suppository, it is most important for the RN to perform which assessment?
answer
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
question
When administering the rectal suppository, RN asks Joan to take several slow, deep breaths. What is the rationale for this instruction?
answer
Relax the anal sphincter and reduce discomfort-deep breathing promotes relax of the anal sphincter, thereby reducing discomfort when the suppository is inserted
question
RN documents the administration of the rectal suppository in the RN's notes. Which notation is correct?
answer
0900. One glycerin suppository administered per rectum for constipation, as prescribed.
question
Which statement provides the best documentation of the outcome from the suppository administration?
answer
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.
question
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?
answer
-radiographic examination -digital rectal examination
question
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?
answer
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)
question
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?
answer
Decreased pulse rate
question
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?
answer
Administer enema as prescribed and obtain the HCP's signature the next day.
question
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?
answer
"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.
question
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?
answer
-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)
question
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?
answer
-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)
question
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
answer
3cups (30mL=1oz, 1c=8oz, 725mL/30=24oz/8=3c
question
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
answer
8-9 8oz cups of fluid daily 1 8oz c=240mL (8x30mL/oz) 2L =2,000mL, 2,000mL/240mL=8.33 c/day
question
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?
answer
fresh fruit salad w/apple and banana slices
question
which breakfast selection by Joan indicates that she understands teaching about dietary measures to promote bowel regularity?
answer
OJ and oatmeal w/raisins