Question

Patient History

History: Car crash resulting in brain Injury (2020)

Complaints: Generalized weakness; loss of bowel and bladder control; difficulty swallowing

•Based on the history and complaints, which body system (s) is/are being compromised?*

3 Nursing Diagnonses

3 Nursing Intervention

3 Patient Education

Answer 1

Nursing diagnosis

1. Risk for injury due to weakness,secondary to brain injury

Nursing Interventions

patients at risk for injury:

Interventions	Rationales
Assess patient ability to do activities to do daily care and own activities Thoroughly conform patient to surroundings. Put call light within reach and teach how to call for assistance; respond to call light immediately.	The patient has to meet his needs otherwise nurse has to provide it so through assessment can identify weather anurse has to support for this patient. The patient must get used to the layout of the environment to avoid accidents. Items that are too far from the patient may cause hazard.
Avoid use of restraints. Obtain a physician’s order if restraints are needed.	If patients are restrained, they can sustain injuries, including strangulation, asphyxiation, or head injury from leading with their heads to get out of the bed.
In place of restraints, utilize the following: Alarm systems with ankle or wrist bracelets Bed or wheelchair alarms Increased observation of patient Locked doors to unit Bed with wheels removed to keep bed low	These are alternatives to restraints that can be helpful for preventing falls and injuries

Nursing diagnosis

2. Imparied bowel elimination, bowel incontinence related to loss of bowel control secondary to brain damage

Assessment

Identify the cause of incontinence.	This information serves as baseline data and provides direction for subsequent interventions.
Assess the patient’s normal bowel elimination pattern.	Every individual has a unique bowel elimination pattern.. Most people feel the urge to defecate soon after the first oral intake of the day such as coffee or breakfast; this is a result of the gastrocolic reflex.
Determine the course of medications or treatments that may contribute to bowel incontinence.	Uncontrollable explosive diarrhea may be the result of hyperosmolar tube feedings, bowel preparation agents, pelvic and abdominal irradiation, some chemotherapeutic agents, and certain antibiotic agents.
Perform manual checkup for fecal impaction.	Liquid stool may leak past the impaction when the patient has hard, dry stool that cannot be expelled normally.
Assist in preparing the patient for several tests.	These procedures are performed to determine the causes of bowel incontinence. Tests include flexible sigmoidoscopy, barium enema, colonoscopy, and anal manometry.so it is required.
Assess the use of diapers, sanitary napkins, incontinence briefs, fecal collection devices, and underpads.	Patients or caregivers may use well-known products such as sanitary napkins to collect fecal material and for protection from bowel leaks, especially at night.
Evaluate the ability of the patient to go to the bathroom independently.	Rearranging the environment can prevent soiling accidents that can happen with the patient’s inability to get to the bathroom.
Assess fluid and fiber intake.	Fiber and fluid are great for normalizing bowel function.
Evaluate the extent to which the patient’s daily activities are modified by bowel incontinence.	The fear of uncontrolled bowel elimination may result in social isolation. Individuals with bowel incontinence are likely to experience soiling of clothing and embarrassment.
Assess perineal skin integrity.	Stool can create chemical sensitivity to the skin, which may be worsened by the use of diapers, incontinence briefs, and underpads.
Evaluate the surroundings for the availability of an accessible toilet facility.	Lacking access to toileting facilities at home, in the work setting, in the shopping mall, and the like can intensify the incontinence experience.

Nursing Interventions	Rationale
Provide a high-fiber diet under the direction of a registered dietician, unless contraindicated.	Insoluble type of fiber promotes the movement of material through the digestive system and increases stool bulk, so it can be of benefit to those who struggle with irregular stools. Bulky stool stimulates peristalsis and expulsion of stool from the bowel.
Ensure fluid consumption of at least 3000 mL/day, unless contraindicated.	This prevents impaction because a moist stool can move through the bowel more easily. If the patient has diarrhea, fluid therapy is vital for volume replacement.
Perform removal of fecal impaction manually, if necessary.	Presence of fecal impaction can interfere with the establishment of a regular bowel routine.
Keep bedside commode and assistive device on sight.	Immediate access to appropriate toileting facilities reduces unnecessary “accidents.”
Encourage the intake of natural bulking agents to thicken stools, for example, foods such as banana, rice, and yogurt.	These foods help provide bulk to the stool by absorbing fluids from the stool.
Assist patient for mobility or exercise, if tolerated.	Movement and exercise stimulate peristalsis and aid in bowel movement.
Create a bowel program.	Promoting regular time for bowel elimination prevents the bowel from emptying sporadically.
Encourage bowel elimination at the same time each day.	Soon after breakfast is the best time because the gastrocolic reflex is stimulated by food or fluid intake.
After breakfast or a warm drink	For some cases, direct stimulation of the rectal sphincter and lower colon may be needed to initiate peristalsis.
Place the patient in an upright position for defecation.	Sitting upright with feet flat on the floor promotes muscular movement that aids in defecation.
Discourage the use of pads, diapers, or collection devices for long-term management of bowel incontinence.	These products can be used on a short-term basis to prevent soiling but may irritate the skin in the long run.
Use fecal collection systems selectively over pads and diapers.	These devices allow for collection and disposal of stool without exposing the perianal skin to stool; odor and embarrassment are controlled because the stool is contained.
Wash the perineal area after each elimination with soap and water. Apply a moisture barrier ointment.	Any fecal material left on the skin may cause irritation, skin excoriation, and pain. This pain may result in fear of defecating and cause the patient to deny the urge to defecate. This may result in impaction and eventually bowel incontinence.
Educate the patient and caregiver the importance of fluid and fiber in maintaining soft, bulky stool.	This improves personal efficacy and can enhance compliance and participation with the therapeutic regimen.
Educate the caregiver the use of a fecal device, if necessary.	This may be challenging but the caregiver has the chance to learn to manage the device with appropriate guidance and feedback.
Educate the patient about proper hygiene and the use of soap and water and moisture barrier containing zinc oxide or dimethicone.	These prevent skin irritation and pain that may lead to fecal impaction and eventually bowel incontinence.
Educate the patient on the importance of establishing a regular schedule for bowel elimination.	Knowledge helps the patient and family understand the rationale for treatment and assists the patient in assuming responsibility for self-care later.

Nursing diagnosis

3.

Nursing Assessment

Assessment is necessary to determine potential problems that may have lead to dysphagia as well as handle any difficulty that may appear during nursing care.

Assess ability to swallow by positioning examiner’s thumb and index finger on patient’s laryngeal protuberance. Ask patient to swallow; feel larynx elevate. Ask patient to cough; test for a gag reflex on both sides of posterior pharyngeal wall with a tongue blade.	The lungs are usually protected against aspiration by reflexes as cough or gag. When reflexes are depressed, the patient is at increased risk for aspiration.
Evaluate the strength of facial muscles.	Cranial nerves VII, IX, X, and XII control motor function in the mouth and pharynx. Coordinated function of muscles innervated by these nerves is necessary to move a bolus of food from the mouth to the posterior pharynx for controlled swallowing.
Check for coughing or choking during eating and drinking.	These signs indicate aspiration.
Observe for signs associated with swallowing problems	These are all signs of swallowing impairment.
Assess ability to swallow a small amount of water.	If aspirated, little or no harm to the patient occurs.
Check for residual food in mouth after eating.	Pocketed food may be easily aspirated at a later time.
Check for food or fluid regurgitation through the nares.	Regurgitation indicated decreased ability to swallow food or fluids and an increased risk for aspiration.
Evaluate the results of swallowing studies as ordered.	A video-fluoroscopic swallowing study may be indicated to determine the nature and extent of any oropharyngeal swallowing abnormality, which aids in designing interventions.
Determine patient’s readiness to eat. Patient needs to be alert, able to follow instructions, hold head erect, and able to move tongue in mouth.	If one of these factors is missing, it may be desirable to withhold oral feeding and do enteral feeding for nourishment. Cognitive deficits can result in aspiration even if able to swallow adequately.

Nursing Interventions

The following are the therapeutic nursing interventions for impaired swallowing:

Nursing Interventions	Rationales
For hospitalized or home care patients:
Before mealtime, provide for adequate rest periods.	Fatigue can further add to swallowing impairment.
Eliminate any environmental stimuli	The patient can more concentrate when external stimuli are removed.
Provide oral care before feeding. Clean and insert dentures before each meal.	Optimal oral care promotes appetite and eating.
For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist who work together.	The dysphagia team can help the patient learn to swallow safely and maintain a good nutritional status.
Place suction equipment at the bedside, and suction as needed.	With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx and upper trachea, increasing the risk of aspiration.
If patient has impaired swallowing, do not feed until an appropriate diagnostic workup is completed. Ensure proper nutrition by consulting with physician for enteral feedings, preferably a PEG tube in most cases.	Feeding a patient who cannot sufficiently swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have shown that there is increased nutritional status and possibly improved survival rates.
If decreased salivation is a contributing factor: Before feeding, provide the patient a lemon wedge, pickle, or tart-flavored hard candy. Use artificial saliva.	Moistening and use of tart flavors stimulate salivation, lubricate food, and improves the ability to swallow.
If patient has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines:
Position patient upright at a 90-degree angle with the head flexed forward at a 45-degree angle.	This position allows the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.
Ensure patient is awake, alert, and able to follow sequenced directions before attempting to feed.	As the patient becomes less alert the swallowing response decreases, which increases the risk of aspiration.
Begin by feeding patient one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow.	Gravy or sauce added to dry foods facilitates swallowing.
Place food on unaffected side of tongue.
During feeding, give patient specific directions (e.g., “Open your mouth, chew the food completely, and when you are ready, tuck your chin to your chest and swallow”).	Proper instruction and focused concentration on specific steps reduce risks.
Maintain the patient in high-Fowler’s position with the head flexed slightly forward during meals.	Aspiration is less likely to happen in this position.
Instruct the patient not to talk while eating. Provide verbal cueing as needed.	Concentration must be focus on the task.
Observe for uncoordinated chewing or swallowing; coughing shortly after eating or delayed coughing, which may mean silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a variation in respiratory patterns. If any of these signs are present, put on gloves, eliminate all food from oral cavity, end feedings, and consult with a speech and language pathologist and a dysphagia team.	These are signs of impaired swallowing and possible aspiration.
Reassure the patient to chew completely, eat gently, and swallow frequently, especially if extra saliva is produced. Give the patient with direction or reinforcement until he or she has swallowed each mouthful.	Such directions assist in keeping one’s focus on the task.
Classify food given to the patient before each spoonful if the patient is being fed.	Knowledge of the consistency of food to expect can prepare the patient for appropriate chewing and swallowing technique.
Advance slowly, giving small amounts; whenever possible, alternate servings of liquids and solids.	This technique helps prevent foods from being left in the mouth.
Encourage high-calorie diet that involves all food groups, as appropriate. Avoid milk and milk products.	Dairy products can lead to thickened secretions.
If patients pouch food to one side of their mouth, encourage them to turn their head to the unaffected side and manipulate the tongue to the paralyzed side.	Foods placed on the unaffected side of the mouth promote more complete chewing and movement of food to the back of the mouth, where it can be swallowed.

Patient education

Assess the patient condition and based on that we have to give education,mainly education regarding patient and also the primary care giver/bistander.

• educate about patient condition and limitation
• provide emotional /psychological support
• educated to follow instruction by the doctors
• advice to take medicine on time
• educate to manage elimination pattern
• educate to take adequcate nutritious food, in appropriate form.
• educate to maintain personal hygiene
• Tell them to avoid infection