Question

CASE

Mrs Smith, 73 years old, was brought to the emergency room due to the in-car traffic accident. As a result of physical examination and diagnostic tests, permanent paralysis (hemiplegia) was determined on the left side and she was admitted to the neurology clinic. Mrs Smith, who has been inactive for a long time, complains of constipation, urinary incontinence, insufficient sleep and is fed with a nasogastric tube due to difficulty swallowing.

QUESTIONS

2. What are the factors that cause constipation in Mrs Smith? Please write nursing interventions for constipation?.

3. Please write the interventions for Mrs Smith to have adequate and balanced sleep?.

4. Write down the mechanisms/physiopathology of respiratory system problems (atelectasis, infection) that may develop in Mrs Smith, who is lying for a long time. And write down the preventive interventions of respiratory system problems (atelectasis, infection) that may develop in Mrs Smith.

5. Write the interventions to prevent the patient from falling down?.

6. What do you do as a nurse to prevent the nasogastric tube from clogging? (10 points)

Answer 1

1.What are the factors that cause constipation in Mrs Smith? Please write nursing interventions for constipation?

constipation is common in those living with paralysis because of changes in the nervous system and immobility. Paralysis disrupts the bowel system and causes complications ranging from constipation to accidents. If you are living with or impacted by paralysis, it is important to understand the digestive tract and how to manage bowel complications to preserve health and quality of life.

Nursing intervention and rationale for constipation

Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically.	Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake.
Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole grains) per day.	Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
Urge patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises.	Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation.
Encourage a regular period for elimination.	Most people defecate following the first daily meal or coffee, as a result of the gastrocolic reflex.
Digitally eliminate the fecal impaction.	Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially older patients, may not be able to pass these stools without manual assistance.
Consider the following examples to minimize rectal discomfort:
· Warm sitz bath	The warmth of the water relaxes muscles before defecation attempts.
· Hemorrhoidal preparations	These over-the-counter preparations shrink swollen hemorrhoidal tissue.
For patients with neurological problems:
Abdominal massage Using the heel of the hand or a tennis ball, apply and release pressure firmly but gently around the abdomen in a clockwise direction.	Abdominal massage has been known to be helpful in neurogenic bowel disorder but not for constipation in older adults.
Digital anorectal stimulation A gloved lubricated finger is lightly inserted into the rectum and moderately rotated in a circular motion. This is performed for about 15 to 20 seconds until flatus/stool is passed.	Digital stimulation increases muscular activity in rectum by raising rectal pressure to aid in expelling fecal matter.
Discuss with a dietitian about dietary sources of fiber.	A person with enough knowledge about the matter will recommend sources of fiber consistent with the patient’s usual eating habits. A patient unaccustomed to a high-fiber diet may experience abdominal discomfort and flatulence; a progressive increase in fiber intake is recommended.
Explain to the patient and caregiver the importance of the following:	These steps lead to establishing regular bowel habits.
· A balanced diet that comprises adequate fiber, fresh fruits, vegetables, and grains	Twenty grams of fiber per day is suggested.
· Sufficient fluid intake (eight glasses per day or 2000 to 3000 mL/day)	Increased hydration promotes a softer fecal mass.
· A regular period for elimination and an adequate time for defection	Successful bowel training relies on routine. Facilitating regular time prevents the bowel from emptying sporadically.
· Regular exercise and activity	Exercise strengthen abdominal muscles and stimulate peristalsis.
· Privacy for defecation	Privacy allows the patient to relax, which can help promote defecation.
Explain the use of pharmacological agent as ordered.	The use of laxatives or enemas is indicated for short-term management of constipation.
· Bulk fiber (Metamucil and similar fiber products)	These laxatives increase fluid, gaseous, and solid bulk of intestinal contents.
· Stool softeners (e.g., Colace)	These laxatives soften stool and lubricate intestinal mucosa.
· Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia)	These laxatives irritate the bowel mucosa and cause rapid propulsion of contents of small intestine.
· Suppositories	These laxatives aid in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.
· Oil retention enema	This intervention softens stool.

2.  Please write the interventions for Mrs Smith to have adequate and balanced sleep?.

Nursing intervention and rationale for balanced sleep

Educate the patient on the proper food and fluid intake such as avoiding heavy meals, alcohol, caffeine, or smoking before bedtime.	Having full meals just before bedtime may produce gastrointestinal upset and hinder sleep onset. Coffee, tea, chocolate, and colas which contain caffeine stimulate the nervous system. This may interfere with the patient’s ability to relax and fall asleep. Alcohol produces drowsiness and may facilitate the onset of sleep but interferes with REM sleep.
Encourage daytime physical activities but instruct the patient to avoid strenuous activities before bedtime.	In insomnia, stress may be reduced by therapeutic activities and may promote sleep. However, strenuous activities may lead to fatigue and may cause insomnia.
Encourage patient to take milk.	L-tryptophan is a component of milk which promotes sleep.
Instruct the patient to follow a consistent daily schedule for rest and sleep.	Consistent schedules facilitate regulation of the circadian rhythm and decrease the energy needed for adaptation to changes.
Remind the patient to avoid taking a large amount of fluids before bedtime.	This will refrain the patient from going to the bathroom in between sleep.
Inhibit the patient from daytime naps unless needed.	Napping can disrupt normal sleep pattern; however, older patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules.
Introduce relaxing activities such as warm bath, calm music, reading a book, and relaxation exercises before bedtime.	These activities provide relaxation and distraction to prepare mind and body for sleep.
Tell patient to write a journal regarding problems before retiring.	Journaling allows the patient to “set aside” problems or any mental activities just before going to sleep.
Suggest an environment conducive to rest or sleep.	A lot of people sleep better in cool, dark, quiet environment.
Prevent the patient from thinking about next day’s activities or any distracting thoughts at bedtime.	Providing a designated time for these concerns allows the patient to “let go” of these problems at bedtime.
Suggest patient to get out of bed temporarily and perform a relaxing activity if unable to sleep 30-45 minutes in bed.	The bed is not supposed to be used for watching TV, work, or wakefulness. The brain should associate the bed with sleeping.
For patients who are hospitalized:
Eliminate any activities that are not important.	This measure facilitates minimal interruption in sleep or rest.
Place patient in a room away from any distraction or noise such as the nursing station.	The nursing station is often the center of noise and activity.
Provide a “Do not disturb” sign on the patient’s room.	It is necessary to alert people in this kind of situation to avoid disruption of sleep.
Render bedtime nursing care such as back rub and other relaxation techniques.	These kinds of activities facilitate relaxation and promote the onset of sleep.
Attempt to allow for sleep cycles at least 90 minutes.	Research shows that 60 to 90 minutes are necessary to complete one sleep cycle and that completion of an entire sleep cycle is beneficial.
Educate patient about their sleep requirements.	Most people need at least six hours sleep for normal memory and brain function.
Help patient understand the main cause of sleeping difficulties.	Misconceptions and myths about sleep exist. Wrong notions about sleep disturbances may cause fear and anxiety.

3. Write down the mechanisms/physiopathology of respiratory system problems (atelectasis, infection) that may develop in Mrs Smith, who is lying for a long time. And write down the preventive interventions of respiratory system problems (atelectasis, infection) that may develop in Mrs Smith.

The mechanism of obstructive and nonobstructive atelectasis is quite different and is determined by several factors.

Obstructive atelectasis

Following obstruction of a bronchus, the blood circulating in the alveolar-capillary membrane absorbs the gas from alveoli. This process can lead to retraction of the lung and an airless state within those alveoli in a few hours. In the early stages, blood then perfuses the unventilated lung. This results in a shunt and, potentially, arterial hypoxemia. Subsequent to obstruction of a bronchus, filling of the alveolar spaces with secretions and cells may occur, thereby preventing complete collapse of the atelectatic lung. The uninvolved surrounding lung tissue distends, displacing the surrounding structures. The heart and mediastinum shift toward the atelectatic area, the diaphragm is elevated, and the chest wall flattens.If the obstruction to the bronchus is removed, any complicating postobstructive infection subsides and the lung returns to its normal state. If the obstruction is persistent and infection continues to be present, fibrosis and/or bronchiectasis may develop.

Nonobstructive atelectasis

The loss of contact between the visceral and parietal pleurae is the primary cause of nonobstructive atelectasis. A pleural effusion or pneumothorax causes relaxation or passive atelectasis. Pleural effusions affect the lower lobes more commonly than pneumothorax, which affects the upper lobes. A large pleural-based lung mass may cause compression atelectasis by decreasing lung volumes.Adhesive atelectasis is caused by a lack of surfactant. The surfactant has phospholipid dipalmitoyl phosphatidylcholine, which prevents lung collapse by reducing the surface tension of the alveoli. Lack of production or inactivation of surfactant, which may occur in acute respiratory distress syndrome (ARDS), radiation pneumonitis, and blunt trauma to the lung, cause alveolar instability and collapse.Middle lobe syndrome (recurrent atelectasis and/or bronchiectasis involving the right middle lobe and/or lingula) has recently been reported as the pulmonary manifestation of primary Sjögren syndrome.Scarring of the lung parenchyma leads to cicatrization atelectasis.Replacement atelectasis is caused by filling of the entire lobe by a tumor such as bronchoalveolar carcinoma.

Platelike atelectasis

Also called discoid or subsegmental atelectasis, this type is seen most commonly on chest radiographs. Platelike atelectasis probably occurs because of obstruction of a small bronchus and is observed in states of hypoventilation, pulmonary embolism, or lower respiratory tract infection. Small areas of atelectasis occur because of inadequate regional ventilation and abnormalities in surfactant formation from hypoxia, ischemia, hyperoxia, and exposure to various toxins. A mild-to-severe gas exchange abnormality may occur because of ventilation-perfusion mismatch and intrapulmonary shunt.

Postoperative atelectasis

Atelectasis is a common pulmonary complication in patients following thoracic and upper abdominal procedures. General anesthesia and surgical manipulation lead to atelectasis by causing diaphragmatic dysfunction and diminished surfactant activity. The atelectasis is typically basilar and segmental in distribution. After induction of anesthesia, atelectasis increases from 1 to 11% of total lung volume. End-expiratory lung volume is also found to be decreased.

preventive interventions

Pre-operative management Using validated assessment tools, the medical history of surgical candidates is evaluated for factors including pre-existing respiratory and/or systemic disease, smoking history, medication use and other factors identified above. Testing for cough and deep breathing is recommended since poor cough effort is a strong predictor for atelectasis and other PPCs.

Active tobacco smokers have a significantly heightened risk for PPCs. Smoking cessation 6–8 weeks before surgery has been shown to be beneficial and is strongly encouraged . Patients with a chronic pulmonary disease may be prescribed increased doses of bronchodilator therapy to reduce bronchial hyperreactivity and increased airway clearance therapy (ACT) to reduce secretion retention and improve the airway patency.Attention to anesthetic technique, ventilator management, fluid monitoring, and surgical technique and duration is fundamental to reduce the risk for atelectasis.The role of anesthesia in development of atelectasis and subsequent PPCs is wellrecognized and an extensive body of literature is focused on surveillance and management procedures.Intraoperative secretion management is critical in MV patients. This is achieved by various methods that include adequate humidification of medical gases and the physical removal of airway secretions via a suction catheter

4. Write the interventions to prevent the patient from falling down?.

1) setting up a discrete highrisk mark that constantly reminded the staff of the patient’s risk

2) reminding the patient’s family members or caregivers of carrying our fall prevention protocol

3) informing the patient how psychotropic medication influence state of consciousness;

4) accompanying the patient to and from therapy/examination premises

5) verifying adequate size of patient’s clothing

6) three 30 seconds (30 seconds from waking up to getting up, 30 seconds from getting up to standing up, 30 seconds from standing up to walking)

7) collecting information on the patient’s balance and/or coordination disorder

8) getting information on the patient’s cognitive abilities and memory

9) assessing the muscle strength everyday and setting up individualized activity plan: grade 0-2, passive activity on the bed; grade 3, active and passive activity on the bed; grade 4, early provision of medical aids to facilitate ambulation under the guide of nurse, with the caregiver accompanying on the paralysis side of the patient; grade 5, normal activity

10) management of urination and defecation according to muscle strength: grade 0-2, using bedpan on the bed; grade 3-4, using chair for urination and defecation on bedside; grade 5, using toilet

11) management of bath according to muscle strength: grade 0-3, ablution on the bed by caregiver; grade 4-5, taking bath in washroom accompanied by caregiver;

12) choosing proper caregiver according to the severity of stroke and bodyweight of the patient; 13) removal of mobile objects near the bed;

14) hourly inspections by nursing staff

15) placing the patient in a room close to the nursing staff room;

16) alerting the patient’s visitors to the fall prevention measures

17) supervision of the fall prevention measures by nursing group leaders and head nurse

5.What do you do as a nurse to prevent the nasogastric tube from clogging? (10 points)

Always flush the tube immediately before and after feeding with at least 30 mL (1 ounce) of water. Never mix medicine with tube feeding unless advised to do so by your healthcare practitioner. Flush tube with at least 30 mL of water before and after all medications.