Jimmy, 35 years old who
works as a freelance grass cutter in a small town. One day, while he was doing
his job on a national road to clear some tall grasses, a small van approached
and hit him at his back which later the driver was identified drunk and caught
to jail. Unfortunately, Jimmy was unconsciously transferred to the
hospital nearby. After a few hours, Jimmy wakes up and didn't remember so much
about the incident. he confined and admitted to the hospital while waiting for
his test results. Suddenly, an alarm rang in the nurses’ station which
indicates that someone must need a nurse's attention and it was at Jimmy's
room. Below is a sample of bowel incontinence nursing care plan of Jimmy
who recently admitted to the hospital due to an incident of being hit by a
small van.
ASSESSMENT
Subjective:
"I'm unable to control my defecation," as verbalized.
Objectives:
I observed from the client that his/her clothing and bedding were stained by feces. The room has a fecal odor which was come from the patient. The patient had a red in his/her perianal skin and there's a soft stool protruding in his/her rectal orifice. Vital signs were taken and noted as follows: Body temperature of 37.5 degrees Celsius, blood pressure of 130/90, and respiratory rate of 18 cycles per minute and pulse rate of 98 beats per minute. Both of his/her respiratory and pulse rate are normal but his/her body temperature and blood pressure is above normal.
DIAGNOSIS
Bowel incontinence
related to inability to control defecation as evidenced by fecal staining of
clothing. (Defecation is a process when a person eliminates his/her own feces).
PLANNING
After 4 hours of nursing
intervention, the patient will participate in therapeutic regimen to control
incontinence and maintain a regular pattern of bowel function.
INTERVENTIONS
- Identify Jimmy's pathophysiological factors he
presents such as multiple sclerosis, acute and chronic cognitive and self-care
impairments, spinal cord injury, stroke, ileus, ulcerative colitis if any.
Review results of his diagnostic studies such as abdominal x-ray, colon
imaging, complete blood count, serum chemistries, stool for blood guaiac as
appropriate. Determine Jimmy's historical aspects of incontinence with
preceding/precipitating events. Review his medication regimen that might
increase his potential for bowel problems. Auscultate Jimmy's abdomen and look
for the presence, location, and tenderness. Palpate his abdomen for distention,
masses and tenderness.
- Establish bowel program worth predictable time for Jimmy's defecation
efforts, use suppositories and digital simulation when indicated. Place bedpan
at specified interval to take into consideration of his needs and incontinent
patterns. Maintain daily program initially. Take Jimmy to the bathroom or place
on commode or bedpan at specific intervals, taking into consideration Jimmy
needs and his incontinence patterns to maximize success of program.
- Promote exercise program, as Jimmy is a individually able, to increase his
muscle tone and strength, including his lower muscles. Provide incontinence aid
or pads until control is obtained. Note that incontinence pads should be
changed frequently to reduced incidence of skin rashes or breakdown.
Demonstrate techniques such as contacting abdominal muscles, leaving forward on
a commode, manual compression to increase intra-abdominal pressure during
defecation, and left to right abdominal massage to stimulation of
peristalsis.
- Refer to ND diarrhea if incontinence is due to uncontrollable diarrhea and ND
constipation if incontinence is due to impaction.
- Instruct Jimmy the use
of suppositories or stool softeners, if indicated to stimulate timed
defecation. Note the stool characteristics such as color, odor, consistency,
amount, shape and frequency to provide a comparative baseline. Identify foods
such as daily bran muffins, prunes that promote regular bowel and encourage the
client in high-fiber diet and adequate amount of warm fluids.
- Provide emotional support to Jimmy, especially when his condition is
long-term or chronic because it enhances his coping with difficult
situation.
EVALUATION
After 4 hours of nursing
intervention, the patient participated in therapeutic regimen to control
incontinence and maintained a regular pattern of bowel function.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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