Nursing Care Plan & Patient Data Base NUR 2230C Advanced Adult Health Care – Fall 2022

Nursing Care Plan & Patient Data Base NUR 2230C Advanced Adult Health Care – Fall 2022Directions: 1) Collect appropriate subjective and objective data utilizing patient interview, observation, physical assessment, chart review and other data sources. 2) Highlight all abnormal findings, problems and needs. 3) Cluster all identified abnormal findings, problems and needs in each section. 4) Highlight the relevant Nursing Diagnoses for each section with possible data, risk factors and/or abnormal findings, from the list of common diagnoses provided. Write in any other pertinent nursing diagnoses. 5) This is to be turned in each week for evaluation by the clinical instructor. Initials _M.V__ Room Number _3102__ Age _83_ Gender _Male_ Ethnicity _Hispanic_ Admission Date _09/19/2022_____________ Admitted From: Home _X_ ECF __ Assisted Living __ Other __ Lives with: _Daughter_ Medical Diagnoses: _No bowel movement for 10 days – Fecal Impaction ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Textbook Description of the Medical Dx Client Presentation of the Disease Etiology – What are causes for the disease? Fecal impaction is an acute or chronic complication of constipation. When a patient is constipated, the stool remains in the large intestine for longer than expected causing the intestine to absorb more water from the feces. The feces are then dried out and turned into a hard mass. A person can develop fecal impaction by eating a low fiber diet, not drinking enough fluids, sedentary lifestyle, and certain medication such as opioid analgesics, antidepressants, and iron supplements. The client presented with  Abdominal pain  Abdominal distention  Difficulty passing stool for 10 days September 8, 2009 1 A+ Keiser University-Miami Campus Nursing Care Plan & Patient Data Base NUR 2230C Advanced Adult Health Care – Fall 2022 Pathophysiology The continuous contact between the hard feces and the colonic mucosa can cause an increase in mucus secretion. Fecal impaction also causes an increase in intraluminal pressure in the colon which causes a decrease in perfusion of the colonic mucosa and wall. The resulting localized inflammation can give rise to colitis, ulcerations, and possible perforation. When stercoral perforation occurs, the most frequent site is the sigmoid colon. Stercoral perforation that occurs in the rectosigmoid region is attributed to feces being hardest in the rectosigmoid. These factors lead to an increased intraluminal pressure and result in hypoperfusion of the antimesenteric wall casing perforation. Client presented with signs and symptoms of fecal impaction. This individual reported to the provider that he has not been able to use the restroom for about 10 days prior to coming into the hospital. Diagnostics – How is condition dx?  Physical exam  A digital rectal exam  Abdominal X-ray  CT scan The client had an abdominal CT scan. The results showed abdominal distention and signs of diverticulitis. Signs & Symptoms  Lower abdominal pain  Inability to pass bowel movements  Rectal fullness/discomfort  Fecal incontinence  Urinary frequency  Nausea  Vomiting The client presented with  Lower abdominal pain  Inability to pass bowel movements for 10 days Medical and Nursing Management  Encourage the patient to increase fluid intake of 1.5-2 L/day  Encourage patient to take  Increased fluid intake  Monitor input and output  Increased fiber intake September 8, 2009 2 A+ Keiser University-Miami Campus Nursing Care Plan & Patient Data Base NUR 2230C Advanced Adult Health Care – Fall 2022 recommended dose of dietary fiber of at least 20-30 g daily  Educate patient about physical activity and exercise  Educate patient about proper administration and use of enemas  Ambulate patient from bed to couch Potential Complications  Bowel perforation  Hemorrhage  Uncontrolled bowel movements  Ulcers  Hemorrhoids  Dehydration The patient presented with Dehydration Reference Source: __________________________________________ Adams, M., Holland, L. N., & Urban, C. Q. (2020). Pharmacology for Nurses: A pathophysiologic approach. Pearson. Adams, M., Holland, L. N., & Urban, C. Q. (2020). Pharmacology for Nurses: A pathophysiologic approach. Pearson. Hinkle, J. L., Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarth's textbook of Medical-Surgical Nursing. Wolters Kluwer. Diagnostic Studies/Procedures (include date, time, indication for the test and result) September 8, 2009 3 A+ Keiser University-Miami Campus Nursing Care Plan & Patient Data Base NUR 2230C Advanced Adult Health Care – Fall 2022 Radiology (X-rays/Scans etc) : _Abdominal CT scan ; 10/18/2022 ; Fecal Impaction Procedures (biopsies, surgery): N/A EKG: N/A Consults: Physical Therapy, Speech Therapy, General surgery Other: __________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Laboratory Studies Test Hospital Norms Date & Value Date & Value Date & Value 1. Explain why test was ordered for the client 2. Correlate the abnormal findings to the client condition CBC WBC 5,000- 10,000/mm3 10/18/202 2 7,050 To look for signs and symptoms of anemia and infection RBC 4.5-5.5 10/18/202 2 5.1 To look for signs and symptoms of anemia and infection HGB M= 13-18 g/dL F=12-16 g/dL 10/18/202 2 To look for signs and symptoms of anemia and infection HCT M= 39%-54% F=36%-48% 10/18/202 2 41% To look for signs and symptoms of anemia and infection Platelets 150,000- 450,000 10/18/202 2 151,000 To look for signs and symptoms of anemia and infection Differential Neutrophils Eosinophils Basophils Lymphocytes Monocytes 2,500- 8,000/mm3 50-500/mm3 25-100/mm3 1,000- 4,000/mm3 100-700/mm3 Electrolytes Na K Cl 135-145 mEq/L 3.5-5.0mEq/L 95-105 mEq/L