Care Plan

    Patient’s Name: Carole Howard

    G.P. Dr. POVEY                        

DATE	IDENTIFIED PROBLEM	SIGNATURE
06/04/2020	Carole is complaining of constipation and has been constipated for four weeks. According to the Bristol Stool scale, she has been passing type 7 stools for the last 3 days.
DATE	SMART OUTCOME / OBJECTIVE	SIGNATURE
06/04/2020	Aim for passing type 3-4 stools as stated by the Bristol Stool scale and relieved from any pain or discomfort within 1-2 days.
DATE	NURSING AND PATIENT LED INTERVENTIONS	SIGNATURE
06/04/2020                         06/04/2020                     06/04/2020         06/04/2020           06/04/20/20             06/04/2020             06/04/2020               06/04/2020               06/04/2020                 06/04/2020         06/04/2020               06/04/2020               06/04/2020                 06/04/2020	Professional Values Start with introducing yourself to Carole, explain your role and ask her what name she preferred to called.   Explain to Carole the purpose of the meeting, the procedure and seek consent.   Ensure privacy and dignity is maintained while carrying out the procedure.   Wash hands following the local Hand Washing Trust Policy.   Assessment   Ask Carole questions regarding her constipation; how many times she goes to the toilet.   Find out about Carole stool type by showing her the Bristol Tool Chart.   Carry out an abdominal assessment to examine for the presence of stool (particularly in the left quadrant), look for signs of distension and palpation.   Question Carole about her diet such as how much food she is eating a day, how many units of alcohol she is drinking each day.   Query about Carole’s previous medical history, to ensure that whether it’s causing her constipation or not.   Ask her whether she experiencing any pain, discomfort and strain during opening bowel; how much pain she is having by measuring with the numeric rating scale for example (0-10). Cramping rectal pain is a red flag   Examine whether Carole’s haemorrhoids have been contributing to her being constipated.   Consider and carry out physical examination if necessary by performing a Digital Rectal Examination (only if you are trained).   Check for red flags by inquiring if Carole has experienced sudden weight loss, has a family history of family cancer, experienced cramping rectal pain also known as Tenesmus. Also, perform a faecal occult blood test to check or the presence of blood in the stool because Carole has haemorrhoids.     Treatment   Advice Carole make dietary changes such as increasing the portion of foods that add fibre to her diet such as whole-grain breads and cereals.   Make lifestyle changes such as exercising most days of the week as physical activity improves muscle activity in the intestines. Carole should simple physical exercises such as jogging in the morning before daily routines.      Recommend Carole to receive a raised toilet seat and/or toilet frame based on her preferences and needs.   Liaise with up G.P. to prescribe Dulcolax for Carole, which will help relive her constipation. Dulcolax causes the intestines to contract in addition to stimulating bowel movement by increasing secretion of fluid from the intestines.   Education   Ask Carole if she understand her condition, educate her how the bowel works and about the possible reasons of her constipation.   Show Carole the Bristol Stool Chart and explain to her about the normal stool types and also advise her to keep a Bowel diary, which will helps show her bowel habit and stool type.   Advise her on the significance of maintaining a well-balanced diet to help her constipation.   Advise her to drink 2 litres of water a day, to have hot coffee, hot lemon water or prune juice before breakfast and explain the importance of fluids intake.     Encourage Carole to take fruits and vegetables 5 a day, food that high in fibre such as cereal, beans, wholegrain breads wheat bran, nuts, seeds, dried fruit, and 25-30 grams of fibre per day. Also, advise him to eat slowly, chew food properly.   Educate Carole about self-abdominal massage techniques, which will help relief Constipation.   Recommend her right types of Physical exercise for example ‘hip thrust’ use the stairs regularly instead of lift and educate her how exercise can have a positive impact on her bowel movement.   Educate Carole on the importance of going to the toilet when the need is felt, show her the ‘Toilet Positioning Guide’ and explain how ‘Squatty Potty’ tool can help with the bowel movement.     Inform Carole the support available to her and how the multidisciplinary team (occupational therapist, dietician and GP) contribution will help her quick recovery.   Explain Carole what will happen next; provide information about how she can contact a member nursing team if necessary.   Review Carole’s progress in 3-5 days

Care plan Rationale

Assessment

Constipation can happen when there is difficulty in emptying the large bowel. Changes in lifestyle can often help resolve it, but sometimes, medical attention may be needed. Various reasons can cause constipation such as when stool passes through the colon too slowly (Rao; Go, 2010). As a result, this will cause the colon to absorb more water and the harder the faeces will become. Common causes of constipation which have all been recognised in patients presenting the medical condition are mobility issues, inadequate diet, medicinal intake and various other illnesses (Collins & Bradshaw, 2016).

Constipation results from ignoring urges to defecate, and causes pain and discomfort and irregularity (Brown et al, 2015). Therefore, as part of the assessment the nurse must ask questions to the patient on the usual defecation pattern, taking into account frequency and timing during the day and if there is any pain or discomfort during bowel movement (Rutter, 2013). Patients who are constipated should defecate whenever they feel the urge (Davis, 2011).

A nurse can then therefore begin discussions asking the patient probing questions to ascertain and assess their physical state. There must be a sense of delicacy when asking personal questions so the patient experiences minimal embarrassment by asking about any pain or strain during bowel opening after understanding the patient’s lifestyle, diet, medication can you then determine their physical condition and offer advice on how to rectify the problems (Rutter, 2013).

Haemorrhoids or piles can also occur due to chronic constipation (Barrett, 2015). Haemorrhoids are described as lumps around and inside the anus (Mann, 2002). The patient needs to be asked if they strain to force out hard stools, this is caused by veins being filled with a pool of blood of the back passage. The skin covering the haemorrhoids along with the veins can be forced out of the anus along with the stool and will be trapped outside. A constipated patient can bleed during the passing of stools. The blood can consist of a clot if the haemorrhoids are not pushed back inside, this is known as thrombosis haemorrhoids, they can be extremely painful and itchy (Collins & Bradshaw, 2016). 

The Bristol Stool Form Scale (BSFS) can be used as a source of reference when trying to detail the pain and issues experienced by the patient. It is a diagnostic medical tool designed to categorize stools into seven different types (Chumpitazi et al 2015). Bowel habits differ in people this includes how often there is bowel movement, bowel movement control, consistency and colour. Any changes in any aspect of these habits during the course of a day will show a change in bowel habits. While some bowel movement can show infections for a temporary period of time, it can also be quite serious and seeking medical advice can prevent the condition from getting worse (Sturm & White, 2019). That is when the Bristol Stool Form Scale (BSFS) can aid the nurse to determine the type of motion passed and how long it has been in the bowel (Noland, et al., 2020).

The patient can also be assessed through physical examination known as Digital Rectal examination DRE, it is defined as a simple procedure healthcare professional utilise to examine other internal organs and the lower rectum (Mahmoud, 2019). It is performed by examining the abnormality mass in the rectum and can help to identify blood in the stool and is useful in diagnosing other health problems, such as prostate gland, prostate cancer and enlarged prostate (benign prostatic hyperplasia).

Treatment

A lack of dietary intake is the most common cause for constipation. Not drinking sufficient amounts of water, and a lack of fibre are the main examples that cause this condition (Rose, 2014). If bowel movement is infrequent and irregular the patient should drink more fluids to relieve constipation to loosen stools. Bernard (2015) advises that 30 g of fibre per day should be aimed to be consumed by adults as well as vegetables. Consuming fruit helps relieve constipation. This is due to juices containing sorbitol that help stimulate bowel movements (Chatterjee, 2019).

Liaising with a GP to prescribe medication may also help the patient with constipation such as Laxatives. There are various types of laxative for example Stimulant laxatives, osmotic laxatives, stool softener laxatives and bulk-forming laxatives (Portalatin & Winstead, 2012). Laxatives are often used if an individual’s lifestyle has not improved for example, drinking plenty of fluids, physical exercises and an increase in the amount of fibre in the diet has not helped (NHS, 2019). Osmotic laxatives such as Lactulose makes the stool softer by drawing water into the bowel, it is swallowed and comes as a sweet syrup, it can also be available on prescription and can be bought from pharmacies (Noland, et al., 2020).

Forootan et al. (2018) argues although it is recommended that an increase in fluid intake to 1.5-2 litres (or 6-8 glasses) per day should help with constipation, there is very little scientific evidence to suggest that this can be effective, except when dehydration occurs. But The National Institute of Diabetes and Digestive and Kidney Diseases (2018) have stated that drinking plenty of water and juices will help to make stools easier to pass, avoid dehydration and relieve constipation.

Furthermore, Woodward (2012) describes how important a ‘good functional position’ is in regard to sitting on a toilet and how it helps constipation. Nurses can show patients the correct toilet position when sitting on a toilet. Woodward (2012) also explains that patients should have their knees higher than their hips, whilst leaning forward and keeping their spine straight with elbows on knees. A foot stool raising their feet would also help when defecating. Evidence suggested by Liu (2011) explains that in order for the anus to open and the rectum to be emptied the anal sphincter muscles need to be relaxed. The ‘Squatty Potty’ tool or Defecation Posture Modification Device (DPMD’s) can help provide the natural squatting position when sitting on the toilet, allowing the bowel to empty more comfortably. Modi et al. (2019) findings have shown that DPMD’s had a positive influence on bowel movement duration, straining patterns, and complete evacuation of bowels.

Exercise can also help speed things up for constipation as exercising is essential for regular bowel movements and the nurse should clearly address this with her patient. By exercising, it helps constipation by lowering the time it takes food to move through the large intestine and also by reducing the amount of water the body absorbs from the stool (Sha et al 2019). Physical activity such as deep breathing, cardio and yoga exercises are very effective for loosening bowels and passing stool comfortably. Pelvic floor exercises work the muscles at the bottom of the pelvis including the bladder and bowel. This then builds enough strength for stool to push through the colon easily. To help ease bloating, gas and improve digestion yoga exercises can help by twisting the torso that crunches the stomach muscles and stimulate the bowels and improve overall digestion. (Sethi, 2018).

Abdominal massages have been known to relieve constipation. Regular massages can relieve constipation by helping release gas and waste products. Other conditions such as stress can also be treated via this method and also reduce pain related to irritable bowel syndrome (McIlwain & Bruce, 2012). McClurg and Lowe-Strong (2011) have approved of this technique who found constipation and abdominal pain syndrome to decrease whilst bowel movements increased by stimulating peristalsis.

A nurse should eventually provide all the relevant leaflets and booklets whilst discussing health issues with the patient. This will help give the patient a clearer understanding to where their health problems lie. Patient teach-back is a patient education strategy. During patient teach-back, nurses should ask patients to repeat health information in their own words helping the patient absorb the information and help the nurse confirm whether the patient has understood what has been discussed. Nurses should also use printed patient education materials that are available. Many hospitals have printed educational brochures, leaflets and information on a website. Patient education materials allow patients and family members to review information in their own time and learn about their health. A nurse can therefore use a variety of communication methods such as verbal and non-verbal, create a positive, warm, and compassionate patient experience whilst delivering meaningful patient education (Henderson, et al., 2012).

References

Brown, D., Edwards, H., Seaton, L., Buckley, T. and Lewis, S. (2015). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 4th ed. Elsevier Health Science, pp.982-985.

Bernard, H., 2015. Homoeopathic treatment of constipation. New Delhi: B. Jain.

Chatterjee, P., 2019. Health and Wellbeing in Late Life: Perspectives and Narratives from India. New Delhi: Springer Nature.

Collins, B. & Bradshaw, E., 2016. Bowel dysfunction: a comprehensive guide for healthcare professionals. Cham: Springer.

Chumpitazi, B.P. 2015. Bristol Stool Form Scale Reliability and Agreement Decreases When Determining Rome III Stool Form Designations. PMC, 28(3), pp. 443-448.

Chumpitazi,B., Self,M M.,  Czyzewski,D I., Cejka,S., Swank,P. and  ShulmanJ. R. (2015). Bristol Stool Form Scale Reliability and Agreement Decreases When Determining Rome III Stool Form Designations. US National Library of Medicine National Institutes of Health . Vol. 28. pp 443-448.