Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

New ‘NHS Reserves’ scheme calls on retired nurses to return to work

The government is calling on retired NHS nurses and colleagues to return to work, as part of a health service “reserves” scheme being launched across the country. The move comes against a backdrop of more than 39,800 nurse vacancies across the NHS in England and…

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District nurses have ‘untapped potential’ to reduce hospital admissions

The NHS is “failing to capitalise” on the skills, knowledge and experience of district nurses as a resource for helping with the avoidance of unplanned hospital admissions, according to a report. Researchers found here was an increasing expectation that community health services and district nursing will contribute to avoiding unnecessary admission…

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Case for mandatory Covid-19 jabs for NHS staff ‘not strong enough’

The government’s case for implementing mandatory Covid-19 vaccinations for NHS staff in England has failed to address how the health service will cope when thousands of staff leave their jobs as a result, a report has warned. A new report, published today by the House…

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Exclusive interview: Pandemic pressures must not risk Mid Staffs repeat

The pressures of the Covid-19 pandemic could help fuel another major care scandal if warning signs are missed and staff concerns are ignored, a leading nurse advocate for workplace openness has warned. Helené Donnelly, a nurse who was threatened by colleagues after speaking out during…

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Child Health Nursing Quiz Series - 19

Booster roll-out to go ‘further and faster’ in response to Omicron

Health and social care secretary Sajid Javid has announced that the booster vaccine will now be rapidly rolled out to all UK adults aged 18 and over, in response to the arrival of the new Omicron variant of Covid-19. The accelaration of the planned expansion…

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Uber renews free food and taxi offer to nurses this Christmas

Nurses and colleagues will once again be able to claim free rides to work and a food voucher this Christmas, as part of an annual festive offer from Uber. The initiative is open to all NHS staff across England, Scotland and Wales and Health and…

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Covid-19: Nurse wellbeing study expanded to ‘identify more ways to help’

A research project into the impact of Covid-19 on the mental health and wellbeing of nurses and colleagues is being extended to uncover the ongoing affect of the pandemic and identify further support measures for those in need. The study, which comes as part of…

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Health service groups welcome measures for new Covid-19 variant

Organisations representing healthcare staff, including nurses, have welcomed the tightening of rules on the wearing of face masks in response to the Omicron Covid-19 variant, but suggested further measures may be needed. Responding to the government’s announcements over the weekend, they highlighted concerns about what…

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Staff member stabbed at London hospital amid ‘rising levels’ of violence

The acting chief nurse of a London hospital trust has warned of “rising levels” of violence and aggression towards staff, following the stabbing of a colleague in the emergency department. The Metropolitan Police has confirmed a man has been charged after a member of staff…

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Contact Dermatitis

 Definition

  • Contact dermatitis is an inflammatory reaction of the skin to physical, chemical, or biologic agents.
  • It may be of the primary irritant type, or it may be allergic.
  • The epidermis is damaged by repeated physical and chemical irritation.
  • Common causes of irritant dermatitis are soaps, detergents, scouring compounds, and industrial chemicals.
  • Predisposing factors include extremes of heat and cold, frequent use of soap and water, and a preexisting skin disease.

Contact Dermatitis

Other types of dermatitis
  • Contact dermatitis is caused by an allergen or an irritating substance. Irritant contact dermatitis accounts for 80% of all cases of contact dermatitis.
  • Atopic dermatitis is very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%–20% of all referrals to dermatologists. Individuals who live in urban areas with low humidity are more prone to develop this type of dermatitis.
  • Dermatitis herpetiformis appears as a result of a gastrointestinal condition, known as celiac disease.
  • Seborrheic dermatitis is more common in infants and in individuals between 30 and 70 years old. It appears to affect primarily men and it occurs in 85% of people suffering from AIDS.
  • Nummular dermatitis is a less common type of dermatitis, with no known cause and which tends to appear more frequently in middle-age people.
  • Stasis dermatitis is an inflammation on the lower legs which is caused by buildups of blood and fluid and it is more likely to occur in people with varicose.
  • Perioral dermatitis is somewhat similar to rosacea; it appears more often in women between 20 and 60 years old.
  • Infective dermatitis is dermatitis secondary to a skin infection
Clinical Manifestations
  • Eruptions when the causative agent contacts the skin.
  • Itching, burning, and erythema are followed by edema, papules, vesicles, and oozing or weeping as first reactions.
  • In the subacute phase, the vesicular changes are less marked and alternate with crusting, drying, fissuring, and peeling.
  • If repeated reactions occur or the patient continually scratches the skin, lichenification and pigmentation occur; secondary bacterial invasion may follow.
Medical Management
  • Soothe and heal the involved skin and protect it from further damage.
  • Determine the distribution pattern of the reaction to differentiate between allergic type and irritant type.
  • Identify and remove the offending irritant; soap is generally not used on site until healed.
  • Use bland, unmedicated lotions for small patches of erythema; apply cool wet dressings over small areas of vesicular dermatitis; a corticosteroid ointment may be used.
  • Medicated baths at room temperature are prescribed for larger areas of dermatitis.
  • In severe, widespread conditions, a short course of systemic steroids may be prescribed.
Nursing Management

Instruct patient to adhere to the following instructions for at least 4 months, until the skin appears completely healed:

  • Find out the cause of the problem.
  • Avoid contact with the irritants, or wash skin thoroughly immediately after exposure to the irritants.
  • Avoid heat, soap, and rubbing the skin.
  • Choose bath soaps, detergents, and cosmetics that do not contain fragrance; avoid using a fabric softener dryer sheet.
  • Avoid topical medications, lotions, or ointments, except when prescribed.
  • Make sure gloves are cotton-lined; do not wear for more than 15 to 20 minutes at a time.
Nursing Care Plan
Nursing Diagnosis
Impaired Skin Integrity

Common Related Factors

  • Contact with irritants or allergens

Defining Characteristics

  • Inflammation
  • Dry, flaky skin
  • Erosions, excoriations, fissures
  • Pruritus, pain, blisters
Expected Outcomes
  • Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin.
Nursing Interventions

Ongoing Assessment

  • Assess skin, noting color, moisture, texture, temperature; note erythema, edema, tenderness.
    • Rationale: Specific types of dermatitis may have characteristic patterns of skin changes and lesions.
  • Assess the skin systematically. Look for areas of irritant and allergic contact.
    • Rationale: Flexural areas (elbows, neck, posterior knees) are common areas affected in atopic dermatitis.
  • Assess skin for lesions. Note presence of excoriations, erosions, fissures, or thickening.
    • Rationale: Open skin lesions increase the patient’s risk for infection. Thickening occurs in response to chronic scratching (lichenification).
  • Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.
    • Rationale: Patients may develop dermatitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to dermatitis.
  • Identify signs of itching and scratching.
    • Rationale: The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification
  • Identify any scarring that may have occurred.
    • Rationale: Long-term scarring may result in body image disturbances.

Therapeutic Actions

  • Encourage the patient to adopt skin care routines to decrease skin irritation:
    • Rationale: One of the first steps in the management of dermatitis is promoting healthy skin and healing of skin lesions.
  • Bathe or shower using lukewarm water and mild soap or nonsoap cleansers.
    • Rationale: Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
  • After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk drying.
    • Rationale: Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
  • Apply topical lubricants immediately after bathing.
    • Rationale: Lubrication with fragrance-free creams or ointments serves as a barrier to prevent further drying of the skin through evaporation. Moisturizing is the cornerstone of treatment. Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea. Lotions are lighter and less emollient than creams. If more moisturizing is required than a lotion can provide, a cream is recommended. These include Keri cream, Cetaphil cream, Eucerin cream, and Neutrogena Norwegian formula. Ointments are the most emollient. Vaseline Pyre Petroleum Jelly or Aquaphor Natural Healing Ointment may be beneficial.
  • Apply topical steroid creams or ointments.
    • Rationale: These drugs reduce inflammation and promote healing of the skin. The patient may begin using over-the-counter hydrocortisone preparations. If these are not effective, the physician may include prescription corticosteroids for topical use. Usual application is twice daily, thinly and sparingly. Do not use with an occlusive dressing, because this potentiates the action and systemic absorption of the steroid. Usual duration of use of topical steroids is up to 14 days in adults.
  • Apply topical immunomodulators (TIMs): Tacrolimus (Protopic) & Pimecrolimus (Elidel)
    • Rationale: Tacrolimus (Protopic) has recently been approved for the treatment of atopic dermatitis. TIMs alter the reactivity of cell-surface immunological responsiveness to relieve redness and itching. In 2005, the Food and Drug Administration advised a potential cancer risk with long-term use of pimecrolimus and tacrolimus based on animal studies.
  • Prepare the patient for phototherapy or photochemotherapy.
    • Rationale: This treatment modality uses ultraviolet A or B light waves to promote healing of the skin. The addition of psoralen, which increases the skin’s sensitivity to light, may benefit patients who do not respond to phototherapy alone.
  • Encourage the patient to avoid aggravating factors.
    • Rationale: Some change in lifestyle may be indicated to reduce triggers.

Nursing Diagnosis
Disturbed Body Image

Defining Characteristics

  • Visible skin lesions

Common Related Factor

  • Verbalizes feelings about change in body appearance
  • Verbalizes negative feelings about skin condition
  • Fear of rejection or reactions of others
Common Expected Outcome
  • Patient verbalizes feeling about lesions and continues daily activities and social interactions.
Nursing Interventions

Ongoing Assessment

  • Assess the patient’s perception of changed appearance.
    • Rationale: The nurse needs to understand the patient’s attitude about visible changes in the appearance of the skin that occur with dermatitis.
  • Assess the patient’s behavior related to appearance.
    • Rationale: Patients with body image issues may try to hide or camouflage their lesions. Their socialization may decrease based on anxiety or fear about the reactions of others.

Therapeutic Interventions

  • Assist the patient in articulating responses to questions from others regarding lesions and contagion.
    • Rationale: Patients may need guidance in determining what to say to people who comment about the appearance of their skin. Dermatitis is not a contagious skin condition.
  • Allow patients to verbalize feelings regarding their skin condition.
    • Rationale: Through talking, the patient can be guided to separate physical appearance from feelings of personal worth.
  • Assist patients in identifying ways to enhance their appearance.
    • Rationale: Clothing, cosmetics, and accessories may direct attention away from the skin lesions. The patient may need help in selecting methods that do not aggravate the skin lesions.

Nursing Diagnosis
Risk for Infection

Risk Factors

  • Impaired skin integrity
  • Severe inflammation
  • Excoriation
Desired Outcome
  • Patient remains free of secondary infection.
Nursing Interventions

Ongoing Assessment

  • Assess skin for severity of skin integrity compromise.
    • Rationale: The skin is the body’s first line of defense against infection. Disruption of the integrity of skin increases the patient’s risk of developing an infection or of scarring.
  • Assess for signs of infection.
    • Rationale: Patients with dermatitis are at highest risk for developing skin infections caused byStaphylococcus aureus. Purulent drainage from skin lesions indicates infection. With severe infections, the patient may have an elevated temperature.

Therapeutic Interventions

  • Apply topical antibiotics.
    • Rationale: Topical antibiotics may be used to treat infections that occur with dermatitis.
  • Administer oral antibiotics.
    • Rationale: Oral antibiotics may be more effective in treating infections on the skin.
  • Encourage the patient to use appropriate hygiene methods.
    • Rationale: Keeping the skin clean, dry, and well lubricated reduces skin trauma and risk of infection.

Nursing Diagnosis
Risk for Impaired Skin Integrity

Risk Factors

  • Severe pruritus
  • Scratches skin frequently
  • Dry skin
Desired Outcome
  • Patient reports increased comfort level and skin remains intact.
Nursing Interventions

Ongoing Assessment

  • Assess severity of pruritus.
    • Rationale: Patients with dermatitis may develop an itch-scratch cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itching. Many patients report the itching to be worse at night, thus disrupting their sleep.
  • Assess skin for excoriations and lichenification.
    • Rationale: Scratching and rubbing the skin in response to the itching increases the irritation of the skin. When papules are scratched, they may break open, causing excoriations that become crusty and infected. Over time, constant rubbing and scratching cause the skin to become thick and leathery (lichenification).

Therapeutic Interventions

  • Encourage the patient to avoid triggering factors.
    • Rationale: Contact with factors that stimulate histamine release will increase itching. Because irritants vary from one patient to another, each patient needs to determine substances and situations that aggravate the dermatitis.
  • Maintain hydration of stratum corneum.
    • Rationale: Application of lubricating creams and ointments serve as a barrier to water evaporation from the skin.  Moist skin is less likely to experience pruritus.
  • Use cool compresses on pruritic areas of the skin.
    • Rationale: Cool, moist compresses help relieve pruritus and itching. Additionally, cool baths with colloidal oatmeal (e.g., Aveeno) can provide relief.
  • Encourage the patient to keep fingernails trimmed short.
    • Rationale: Long fingernails used for scratching are more likely to cause skin trauma and aggravate itching.
  • Administer antihistamine drugs.
    • Rationale: Antihistamines such as hydroxyzine will help relieve itching and promote comfort. These drugs can be taken at bedtime. Their sedative effect may also help promote sleep. During the daytime, nonsedating antihistamines may increase the efficacy of pruritus control. Loratadine is an over-the-counter medication.
  • Apply topical antipruritic agents if indicated.
    • Rationale: These may be used alone or combined with oral antihistamines. Over-the-counter products include Sarna lotion, Prax lotion, and Itch-X gel. Prescription Cetaphil with menthol may also help.
  • Apply topical steroid creams if indicated.
    • Rationale: Do not apply on the face. Use thinly and sparingly, up to a maximum of 14 days. Do not use with occlusive dressings.
  • Administer oral steroids.
    • Rationale: Short-term low-dose oral steroids may be ordered for severe cases. Oral steroids are not indicated for long-term use despite their efficacy


Diclofenac

 Drug Name

Generic Name : diclofenac, diclofenac potassium, diclofenac sodium

Brand Name: Cataflam, Novo-Difenac-k (CAN), Voltaren Rapide (CAN), Novo-Difenac (CAN), Novo-Difenac SR (CAN), Nu-Diclo (CAN), Solaraze, Voltaren, Voltaren nu-Diclo SR (CAN), Ophtha (CAN), Voltaren-XR

Classification: Anti-inflammatory, NSAID

Pregnancy Category B

Dosage & Route
ADULTS

Oral

  • Pain, including dysmenorrhea: 50 mg tid PO; initial dose of 100 mg may help some patients (Cataflam).
  • Osteoarthritis: 100–150 mg/day PO in divided doses (Voltaren); 50 mg bid–tid PO (Cataflam).
  • Rheumatoid arthritis: 150–200 mg/day PO in divided doses (Voltaren); 50 mg bid–tid PO (Cataflam).
  • Ankylosing spondylitis: 100–125 mg/day PO. Give as 25 mg qid, with an extra 25-mg dose hs (Voltaren); 25 mg qid PO with an additional 25 mg at bedtime if needed (Cataflam).

Topical

  • Actinic keratosis: Cover lesion with gel and smooth into skin; do not cover with dressings or cosmetics (Solaraze).

Ophthalmic

  • 1 drop to affected eye qid starting 24 hr after surgery for 2 wk.
PEDIATRIC PATIENTS
  • Safety and efficacy not established.
Therapeutic actions
  • Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors.
Indications
  • Acute or long-term treatment of mild to moderate pain, including dysmenorrhea
  • Rheumatoid arthritis
  • Osteoarthritis
  • Ankylosing spondylitis
  • Treatment of actinic keratosis in conjunction with sun avoidance
  • Ophthalmic: Postoperative inflammation from cataract extraction
Adverse effects
  • GI disturbances; headache, dizziness, rash; GI bleeding, peptic ulceration; abnormalities of kidney function. Pain and tissue damage at Inj site (IM); local irritation (rectal); transient burning and stinging (ophthalmic).
  • Potentially Fatal: Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis.
Contraindications
  • Active peptic ulcer; hypersensitivity to diclofenac or other NSAIDs. Treatment of perioperative pain in CABG surgery. 3rd trimester of pregnancy. Topical: Not to be applied onto damaged or nonintact skin.
Nursing considerations
Assessment
  • History: Renal impairment; impaired hearing; allergies; hepatic, CV, and GI conditions; lactation, pregnancy
  • Physical: Skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation, peripheral sensation; P, edema; R, adventitious sounds; liver evaluation; CBC, clotting times, renal function tests, LFTs, serum electrolytes, stool guaiac
Interventions
  • BLACK BOX WARNING: Be aware that patient may be at increased risk for CV events, GI bleed, renal insufficiency; monitor accordingly.
  • Administer drug with food or after meals if GI upset occurs.
  • Arrange for periodic ophthalmologic examination during long-term therapy.
  • WARNING: Institute emergency procedures if overdose occurs (gastric lavage, induction of emesis, supportive therapy).
Teaching points
  • Take drug with food or meals if GI upset occurs.
  • Take only the prescribed dosage.
  • You may experience these side effects: Dizziness, drowsiness (avoid driving or using dangerous machinery while using this drug).
  • Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision; black, tarry stools.

Glowing tributes paid to mental health nursing leader after sudden death

An accomplished mental health nurse and nursing leader who worked on “making the service better”, has died suddenly aged 56. Elaine Thompson, who was most recently interim lead nurse for quality and contracts at NHS East Leicestershire and Rutland Clinical Commissioning Group (CCG), died on…

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Medical-surgical Nursing Quiz Series - 24

Nurse Baby helps deliver baby on plane during ‘eventful flight’

A nurse called Leela Baby has been given an award after she helped to deliver a baby on an aeroplane. Ms Baby, a senior oncology specialist nurse at the University Hospitals Sussex Foundation Trust, was called into action as she travelled on a long-haul flight…

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RCN members working for Marie Curie urged to vote on improved pay offer

A ballot has opened for Marie Curie workers, who are Royal College of Nursing members, to vote on an improved pay offer that has been put forward by the charity following negotiations. RCN members will be able to vote until 9am on 14 December. "This…

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First winner revealed of award launched in memory of nurse Julie Bolus

An “innovative and committed” mental health manager has been crowned the winner of a new rising star nursing award, created in honour of an inspirational nurse leader who died earlier this year. Stephen Harrison, early intervention service hub manager at Birmingham and Solihull Mental Health…

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Pressures in emergency departments leaving nurses ‘increasingly desperate’

More than half of emergency departments are having to treat patients in corridors and other non-designated areas, a survey from the Royal College of Emergency Medicine (RCEM) has found. The snap survey of RCEM members found that 49% of those that responded said they had…

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Exclusive: Nurse pay ‘most discussed’ issue on social media by health workforce

The government’s decision to initially recommend a 1% pay award for nurses was the most discussed NHS policy issue among health professionals on social media over a year-long period, it has been revealed. Analysis given to Nursing Times showed in March 2021 more than 22,000…

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Community Health Nursing Quiz Series - 18

Every region of England sees rise in nurse vacancies over last year

New data has revealed a further “sharp rise” in the number of nurse vacancies in the NHS in England, as the government is once again urged to take action. Latest figures published today by NHS Digital showed, as of September 2021, there were 39,813 nurse…

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Painting in honour of Mary Seacole unveiled at London hospital

A hospital in London has unveiled a new painting honouring Crimean War nursing pioneer Mary Seacole in the hope it will allow patients and staff to “sit, reflect and be inspired by her”. The painting, which depicts Ms Seacole in 1857 in her home in…

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Simulation activity allowance to double for some nursing students

The number of simulation hours nursing students can undertake as part of their clinical practice requirements is set to double for universities that prove they have the “capacity and capability” to do so. The Nursing and Midwifery Council’s governing council has agreed to increase the…

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Constipation

 Definition

Constipationcostiveness, or irregularity, is a condition of the digestive system in which a person experiences hard feces that are difficult to expel.Constipation

  • This usually happens because the colon absorbs too much water from the food. If the food moves through the gastro-intestinal tract too slowly, the colon may absorb too much water, resulting in feces that are dry and hard.
  • Defecation may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction.
Causes of constipation:
  • may be dietary
  • hormonal
  • anatomical a side effect of medications (e.g. some opiates)
  • or an illness or disorder.
Clinical Manifestations
  • Fewer than three bowel movements per week, abdominal distention, and pain and pressure
  • Decreased appetite, headache, fatigue, indigestion, sensation of incomplete emptying
  • Straining at stool; elimination of small volume of hard, dry stool
  • Complications such as hypertension, hemorrhoids and fissures, fecal impaction, and megacolon
Assessment and Diagnostic Methods
  • Diagnosis is based on history, physical examination, possibly a barium enema or sigmoidoscopy, stool for occult blood, anorectal manometry (pressure studies), defecography, and colonic transit studies.
  • Newer tests such as pelvic floor MRI may identify occult pelvic floor defects.

stoolclassification

Medical Management
  • Treatment should target the underlying cause of constipation and aim to prevent recurrence, including education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives.
  • Discontinue laxative abuse; increase fluid intake; include fiber in diet; try biofeedback, exercise routine to strengthen abdominal muscles.
  • If laxative is necessary, use bulk-forming agents, saline and osmotic agents, lubricants, stimulants, or fecal softeners.
  • Specific medication therapy to increase intrinsic motor function (eg, cholinergics, cholinesterase inhibitors, or prokinetic agents).
Nursing Management
Assessment
Use tact and respect with patient when talking about bowel habits and obtaining health history.

Note the following:

  • Onset and duration of constipation, current and past elimination patterns, patient’s expectation of normal bowel elimination, and lifestyle information (eg, exercise and activity level, occupation, food and fluid intake, and stress level).
  • Past medical and surgical history, current medications, history of laxative or enema use.
  • Report of any of the following: rectal pressure or fullness, abdominal pain, straining at defecation, and flatulence.
  • Sets specific goals for teaching; goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications.
Nursing Care Plan
Nursing Diagnosis
  • Constipation

May be related to

  • Functional Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting, abdominal muscle weakness
  • Psychological Depression; emotional stress; mental confusion
  • Pharmacological Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal antiinflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
  • Mechanical Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung’s disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity
  • Physiological Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating patterns; dehydration
Desired Outcomes
  • Maintains passage of soft, formed stool every 1 to 3 days without straining
  • States relief from discomfort of constipation
  • Identifies measures that prevent or treat constipation
Nursing Interventions
  • Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; alterations in perianal sensation; present bowel regimen.
    • Rationale: There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination.
  • Have the client or family keep a diary of bowel habits including time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation.
    • Rationale: A diary of bowel habits is valuable in treatment of constipation.
  • Review client’s current medications.
    • Rationale: Many medications affect normal bowel function, including opiates, antidepressants, antihypertensives, anticholinergics, diuretics, anticonvulsants, antacids containing aluminum, iron supplements, and muscle relaxants.
  • Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds.
    • Rationale: In clients with constipation the abdomen is often distended with a palpable colon.
  • Check for impaction; perform digital removal per physician’s order. If impaction is present, use cleansing regimen until you obtain a very soft stool. If using an enema, the client must be able to bodily retain the fluid. If the client has poor sphincter tone, use a cone tip irrigating bag to assist the client in retaining the fluids.
    • Rationale: This also decreases the amount of fluid necessary for cleansing.
  • Provide privacy for defecation. Assist the client to the bathroom and close the door if possible.
    • Rationale: Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
  • Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually.
    • Rationale: Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Dietary supplements of fiber in the form of bran or wheat fiber are helpful for women experiencing constipation with pregnancy.
  • Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve.
    • Rationale: Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
  • Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths.
    • Rationale: Activity, even minimal, increases peristalsis, which is necessary to prevent constipation.
  • At each meal, sprinkle bran over client’s food as allowed by client and prescribed diet. Ensure that client receives adequate fluid (1500 ml/day) along with bran.
    • Rationale: The number of bowel movements is increased and the use of laxatives is decreased in a client who eats wheat bran. A study done on institutionalized elderly male clients with chronic constipation demonstrated that with bran use, clients were able to discontinue use of oral laxatives.
  • Initiate a regular schedule for defecation, using the client’s normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex.
    • Rationale: A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation.
  • Emphasize to the client the necessary ingredients for a normal bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation). Help client onto bedside commode or toilet with client’s hips flexed and feet flat. Have client deep breathe through mouth to encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation.
  • Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided.
    • Rationale: Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
  • For the stable neurological client, consider use of a bowel routine of Therevac enema or suppositories every other day, or performing digital stimulation with physician’s permission. For persistent constipation, refer to physician for evaluation.
    • Rationale: Use of the Therevac SB mini-enema was found to cut time needed for bowel care by as much as one hour or more as compared with use of suppositories.

Geriatric

  • Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool.
    • Rationale: Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly.
  • Determine client’s perception of normal bowel elimination; promote adherence to a regular schedule.
    • Rationale: Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives.
  • Explain Valsalva’s maneuver and the reason it should be avoided.
    • Rationale: Valsalva’s maneuver can cause bradycardia and even death in cardiac patients.
  • Respond quickly to client’s call for help with toileting.
  • Avoid regular use of enemas in the elderly.
    • Rationale: Enemas can cause fluid and electrolyte imbalances ( and damage to the colonic mucosa.
  • Use opioids cautiously.
    • Rationale: If ordered, use stool softeners and bran mixtures to prevent constipation. Use of opioids can cause constipation.
  • Position client on toilet or commode and place a small footstool under the feet.
    • Rationale: Placing a small footstool under the feet increases intraabdominal pressure and makes defecation easier for an elderly client with weak abdominal muscles.

Home Care Interventions

  • Put client in bathroom to toilet when possible.
    • Rationale: Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
  • Carefully monitor bowel patterns of clients under pain management with opioids. Introduce a bowel management program at first sign of constipation.
    • Rationale: Constipation is a major problem for terminally ill or hospice clients who may need very high doses of opioids for pain management.
  • When using a bowel program, establish a pattern that is very regular and allows client to be part of family unit.
    • Rationale: Regularity of program promotes psychological and/or physiological “readiness” to evacuate. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete.

Client/Family Teaching Nursing care plans For Constipation

  • Instruct client on normal bowel function and the necessity of fluid, fiber, and activity in a bowel program.
  • Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice.
    • Rationale: Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. This results in accumulation of a large, dry fecal mass.
  • Encourage client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if used regularly.
  • If not contraindicated, teach client how to do bent-leg sit-ups to increase abdominal tone; also encourage client to contract abdominal muscles frequently throughout the day.
    • Rationale: Help client develop a daily exercise program to increase peristalsis.