NR 325 CJE
Name: Martha Tass
Age: 88 years
Provider: H. Severs MD
Allergies: sulfonamides
Code Status: DNR
Admit Wt: 118 lbs (53.5 kg)
BMI: 19.6
· Nursing
·
·
·
·
·
· Other
| NURSING ASSESSMENT & NOTES | |
| 3/5 1515 | Neuro: Alert, oriented x 4. Speech clear.
GI: BS present, hypoactive x 4 quadrants. Abdomen soft, distended, non-tender. Last bowel movement x 2 days ago. +flatus. GU: Yellow, clear. Occasionally stranding. Pain: Rates 6/10 abdominal cramping that is intermittently sharp. |
| 3/5 1500 | N>ursing Note: Report received from J. Young, RN. Client on commode visibly straining and grimacing. Client states, “I just need to sit here a little while.” Reporting small amounts of diarrhea stools leaking from rectum. Call bell given. |
| 3/5 1515 | Nursing Note: Client ambulates with a steady gait back to bed. States, “I couldn’t go.” Reports decreased appetite and drink approx. 120 mL of fluid today. “It hurts so much I don’t want anything.” |
| 3/5 1525 | Nursing Note: Dr. Severs made aware of client constipation. Verbal orders with readback for verification completed. |
| 3/5 1600 | Nursing Note: Medications administered per MAR. Client agreeable to enema. |
Before answering this question, review the client’s health information in the EHR. Identify the data that could contribute or does not contribute to the client’s problem. Select one option in each row.
| Contributing | Not Contributing | |
| Surgical History | ||
| Hemorrhoids | ||
| Depression | ||
| Docusate sodium | ||
| Rheumatoid arthritis | ||
| Oxycodone IR |
Feedback
Consider:
1. What are other factors that can contribute to constipation?
2. What medications listed in the client’s EHR impact bowel function?
3. What social factors can impact bowel habits?
Question 2
Complete
Mark 0.00 out of 33.34
Question text
Name: Martha Tass
Age: 88 years
Provider: H. Severs MD
Allergies: sulfonamides
Code Status: DNR
Admit Wt: 118 lbs (53.5 kg)
BMI: 19.6
· Nursing
·
· Provider
·
·
·
· Other
| 3/5 1500 | Medical History:
· Rheumatoid arthritis · Hypertension · Peripheral vascular disease · Depression · Irritable bowel syndrome · Breast cancer · External hemorrhoids · Chronic back pain Surgical History: · Hysterectomy · Bilateral radical mastectomy |
| 3/5 1500 | Home Medications:
· Lisinopril 20 mg by mouth once daily · Escitalopram 20 mg by mouth once daily · Methotrexate 7.5 mg by mouth twice weekly · Oxycodone IR 5 mg by mouth q6h PRN · Acetaminophen 650 mg by mouth q6h PRN · Polyethylene glycol 17 g by mouth daily PRN · Docusate sodium 100 mg by mouth three times daily PRN |
Before answering this question, review the client’s health information in the EHR. Complete the sentence using the drop-down choices.
The nurse recognizes that the priority action is to Blank 1 Question 2 encouraging oral fluidsadminister enemaadministering a stool softenerambulating the client . The nurse will need to Blank 2 Question 2 assess bowel soundsmonitor intakemonitor for dizzinessobtain an abdominal x-ray .
Feedback
Consider:
1. What education should the nurse provide to the client before the enema?
2. What equipment should the nurse gather?
3. Are there any contraindications to completing an enema?
Question 3
Complete
Mark 0.00 out of 33.33
Question text
Name: Martha Tass
Age: 88 years
Provider: H. Severs MD
Allergies: sulfonamides
Code Status: DNR
Admit Wt: 118 lbs (53.5 kg)
BMI: 19.6
· Nursing
· Provider
·
·
·
· Other
| 3/5 1500 | Medical History:
· Rheumatoid arthritis · Hypertension · Peripheral vascular disease · Depression · Irritable bowel syndrome · Breast cancer · External hemorrhoids · Chronic back pain Surgical History: · Hysterectomy · Bilateral radical mastectomy |
| 3/5 1500 | Home Medications:
· Lisinopril 20 mg by mouth once daily · Escitalopram 20 mg by mouth once daily · Methotrexate 7.5 mg by mouth twice weekly · Oxycodone IR 5 mg by mouth q6h PRN · Acetaminophen 650 mg by mouth q6h PRN · Docusate sodium 100 mg by mouth three times daily PRN |
| 3/5 1650 | Client & Family Education: What: Bowel Training Goals: Client will verbalize methods of promoting improved gastric emptying. Interventions:
· Toilet approximately one hour after meals · Toilet at the same time every day · Drink warmed fluids with meals · Support legs during toileting · Unhurried, private environment · Position client to lean forward, press hand gently on abdomen · Discourage straining · Pelvic floor muscle strengthening |
Before answering this question, review the client’s health information in the EHR. Identify statements from the client that require additional teaching from the nurse. Select the correct answer using the drop-down choices in each group.
Nutrition: Blank 1 Question 3 “I need at least 30 grams of fiber.””I drink warmed fluids at each meal, so I don’t need to drink much.””I like drinking warmed cider or coffee at each meal.”
Constipation Pathophysiology: Blank 2 Question 3 “My other medical problems can make constipation worse.””I need to keep using the bowel stimulants every day.””Chewing my food well can help reduce constipation”
Bowel Training: Blank 3 Question 3 “I can set my legs on a stool to create a better position.””I can use Kegel exercises to help strengthen those muscles.””If I don’t feel any urge, I should wait to go to the bathroom.”
Feedback
Consider:
1. What additional teachings should the nurse provide the client?
2. How should the nurse respond to a client becoming frustrated with lack of results during bowel training?
3. Review with a classmate how you would educate a client on Kegel exe