Nurse Care Plan

OVERVIEW

• To evacuate the bowel of stool caused by constipation.
• To cleanse the bowel prior to surgery or other procedures for which the bowel, colon, and rectum are visualized.

• Determine patient’s ability to understand procedure.
• Assess patient’s ability to participate in procedure, such as holding contents when administered.

• Patients who have had recent surgery, or who have arthritis, a cast, lower limb amputations, or fractured pelvis may need additional time for the procedure, owing to limited physical mobility.
• Patients with cardiac history or spinal cord injury may be at risk for complications from vagal stimulation.

• May need more time and instruction of the procedure for optimal participation and results.

• Care should be taken in insertion of the enema tube and instillation of the solution to prevent injury to anus and colon during the procedure.
• Parents should be allowed to comfort infants and children and participate in the procedure.

• Constipation related to decreased peristalsis
• Chronic pain related to abdominal discomfort and distention from bowel malfunction
• Potential for injury related to abdominal distention and trauma to the anus and colon during the procedure

• Patient will return to an optimal bowel elimination pattern
• Patient is able to assist/participate
• Patient will be able to evacuate feces from rectum and colon after the enema
• Patient experiences minimal discomfort during procedure and no injury to the colon and/or anus
• Patient experiences relief and comfort after procedure

• Regular bedpan, fracture pan, or bedside commode
• Water-soluble lubricant
• Clean gloves
• Toilet paper
• Disposable, absorbent bed pads
• Skin care items (i.e., soap or skin cleanser,water, towels)
• IV pole
• Enema container with tubing, normal saline, tap water, soap solution, or commercially prepared enema.

• Check prescriber’s order; identify patient; explain purpose, procedure, and how patient can assist. Assess patient’s ability to participate.
• Confirms order; meets patient’s right to be informed; encourages cooperation and participation.
• Gather all equipment and place in an easy to access area in patient’s room; adjust lighting as needed.Promotes organization of equipment; saves time; and adjusted lighting enhances visualization for procedure.

• Explain to the patient the benefits of relaxing and taking periodic deep breaths. Reduces anxiety and promotes comfort.
• Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms, and prevents contact with urine and/or feces.
• After determining patient’s ability to assist, place disposable waterproof pad under patient. Have patient lift hips or roll from side to side.
• Bed pad protects against soiling of linens.
• Place patient in a left side-lying position with knees flexed. To facilitate flow of solution using contour of the bowel.
• Place bedpan next to patient. For easy access in case patient cannot hold enema solution.

• Fill enema container with 750 mL to 1000 mL of warm solution and check temperature by dripping some solution on inner wrist. If too warm, empty container and refill. Add soap solution if ordered. This amount of solution is the standard volume unless a specific amount is ordered by the physician. This amount is normally what is tolerated; solutions that are too hot or too cold can cause cramping, damage to the rectal mucosa, or extreme shock.
• Allow the solution to run through the tubing to clear out the air; clamp tubing and hang on an IV pole approximately 12 to 18 inches above the patient’s buttocks. Aids in removing air from the tubing that could cause abdominal cramping if instilled into the colon during the procedure; 18 inches is considered a high height, and 12 inches is considered a low height. The higher the pole, the faster the solution will enter the colon.
• Lubricate tip of tubing with generous amount of water-soluble lubricant. Facilitates easier insertion of tubing into the rectum.
• Spread the buttocks, and gently insert the tip of the tubing 3 to 4 inches while the patient is instructed to take slow deep breaths. 3 to 4 inches is the correct placement of tubing in the rectum to allow solution to enter the colon without leakage; slow, deep breaths aids in relaxation of the rectal sphincter.
• Open the regulating clamp and allow the solution to flow slowly. When the solution is instilled slowly, less cramping is experienced by the patient, and the patient will be able to tolerate more volume of the solution.
• Hold the tubing in place in the patient’s rectum at all times, and keep the bedpan nearby. The tubing will slip out easily if not held in place; the patient may need to expel contents before expected.
• Lower the solution container or clamp tubing if the patient complains of cramping, then resume after a few minutes. Lowering the container will slow down the flow of solution and aid in decreasing cramps.
• After solution is instill, clamp tubing and gently remove. Prevents siphoning out enema solution as tube is removed.
• Instruct the patient to hold the solution about 10 to 15 minutes or longer as tolerated. The longer the solution is retained, the more effective the results.
• Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces.
• Instruct patients with cardiovascular disease not to strain when expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest.
• Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms.
• Assist patient back to bed as needed and into a comfortable position. Patient comfort.
• Dispose of enema equipment and clean bedpan or bedside commode as needed. Prevents transmission of infectious microorganisms.
• Remove gloves and wash hands. Prevents transmission of infectious microorganisms.

• Prepare patient and environment as described in first section.
• Lubricate tip of enema container as needed (most are prelubricated). Facilitates easier insertion into the rectum.
• Spread buttocks and insert the tip into the rectum.
• Gently squeeze entire contents of the container. Aids in optimal results if all solution is instilled.
• Remove the tip while continuing to squeeze the container. To prevent the solution from being siphoned back into the container.
• Instruct the patient to hold the solution at least 5 to 7 minutes. To ensure optimal results.
• Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces.
• Instruct patients with cardiovascular disease not to strain when expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest.
• Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms.
• Assist patient back to bed as needed and into a comfortable position. Patient comfort.
• Dispose of enema equipment, and clean bedpan or bedside commode as needed. Prevents transmission of infectious microorganisms.
• Remove gloves and wash hands. Prevents transmission of infectious microorganisms.

• Evaluate patient compliance and ability to tolerate procedure
• Administration of an enema is done correctly, safely, and successfully
• An optimal pattern of elimination is maintained or restored

• Record date, time, type, and results of enema administration, as well as amount and other important characteristics of stool (as required in the designated area on the patient record).
• Record patient’s tolerance of procedure and any complications that occurred.
• Report patient teaching about prevention of constipation.

Thinking through each individual situation and applying the following
simple principles when moving and handling will enable you to maintain
health and safety whilst undertaking the task.

• Assessment of the task
A full and comprehensive assessment should be made of the task before undertaking the move. This assessment of all aspects of the task will enable you to identify risks and hazards and to problem solve to enable the undertaking of safe manoeuvres.

• Maintain a stable base
Position the feet slightly apart, with the lead foot pointing in the direction of movement.
Stability provided by positioning the feet in such a way will prevent loss of balance and falling or twisting during the manoeuvre. When moving and handling a client, for example from one bed to another, it may seem impossible to keep both feet on the floor to provide a stable base without over stretching. It is possible and the situation should be reassessed so as to ensure a stable base whilst undertaking the move. If this is difficult seek guidance from the in-house moving and handling trainer.

• Lower the centre of gravity
By bending or flexing the knees slightly, the centre of gravity will be lowered. This bending of the knees will not only help the posture to be more relaxed and less taut but also provide more stability.

• Keep the spine in line
The spine’s natural curves should be maintained in their normal position, often referred to as ‘in line’, to prevent the occurrence of injury during movement and handling activities. Keeping the spine ‘in line’ also means avoiding top-heavy postures and positions where the spine is twisted or
rotated at any point.

• Keep the load close to your body
Keeping the load close to the body reduces the strain/effort involved in the manoeuvre, by having the load closer to the centre of gravity. It increases efficiency of the movement. It reduces the likelihood of injury.

• Move your head up
Raising the head in an upward direction/movement when undertaking a move leads the body in its movement and helps maintain good posture throughout.

• Holds
Holds used should be relaxed palm-type holds or stroking. Grasping or direct holds should not be used. Using indirect holds allows the hold to be released should the manoeuvre be beyond one’s abilities and reduces the likelihood of injury. Stroking down clients’ limbs to aid in their movement is gentler for the client and they are less likely to respond by suddenly withdrawing the limb, which could result in one being jerked or injured.

• Remember individual capabilities
Remember to consider the individual capabilities of all concerned in the manoeuvre; this includes you and your colleagues as well as the client. Those who have had previous injuries, or pregnant women, may be at greater risk when moving and handling.

• Know the equipment
It is important to know not only what equipment is available, but also how to use it correctly and to its fullest potential. One should also be aware of the correct methods for sizing of slings/accessories to ensure these are used correctly. The maximum safe working load of all pieces of equipment used in the area should be known. Equipment should be well maintained and serviced regularly. Do not use if faulty and ensure that faulty equipment is labelled as such and reported immediately. All equipment should be checked at least annually and a record kept.

• Good communication
Good communication is important so that everyone involved in the manoeuvre is aware of what their responsibilities are in relation to the move, and when the manoeuvre is to take place. This will also help to ensure that the move is carried out at the correct time in an organized manner.
Communication with the client is also vital not only to ensure their co-operation but also to maintain their trust and confidence.

• Controlled manoeuvres
Remember that manoeuvres need to be controlled and taken in stages if necessary to avoid over-stretching for those undertaking the move and to avoid discomfort or fear for the client.

• Wear appropriate clothing and footwear
Wearing correctly fitting and appropriate clothing will enable free movement without being restricted. Correct footwear will ensure good stability and grip and thus prevent over-balancing or slipping.

• Avoid manual handling
Manual handling, that is, physically moving objects or persons, should be avoided if at all possible.

Remembering these principles and being able to apply them in the variety of movement and handling tasks undertaken both in the workplace and in everyday life will enable problem solving and the identification of safe solutions in respect of movement and handling.
Adopting these principles will provide a more flexible approach to manual handling than learning a specific move for a specific situation, where in real life other factors involved often make such specific manoeuvres learnt unsuitable or unachievable in the practice setting.

1. to relieve urinary retention.
2. To obtain a sterile urine specimen from a woman.
3. To measure the amount of residual urine in the bladder.
4. To obtain a urine specimen when a specimen cannot be secured satisfactorily by other means.
5. To empty the bladder before and during surgery and before certain diagnostic examinations.

1. Assemble equipments. Be sure to wash your hands thoroughly.
2. Have the patient lie on a firm mattress.
3. Provide for good light.
4. After providing for privacy, position the patient in a dorsal recumbent position, with the knees flexed and feet about 2 feet apart, and drape the patient.
5. If the patient is soiled, wash the area around the meatus well with soap or detergent and water, then rinse and dry.
6. After putting on sterile gloves, arrange the sterile equipment for convenience and to avoid contamination.
7. Place the sterile drapes adjacent to the meatal area. Use the drape corners to wrap around the gloved hands.
8. Lubricate the catheter fro about 3.7 cm being careful not to fill the eyes of the catheter.
9. Place the thumb and one finger between the labia minora, and identify the meatus.
10. Be prepaired to maintain separation of the labia with one hand until urine is flowing well and continously.
11. Cleanse the exposed area at the meatus thoroughly using the solution of the agencys choice. Move the cotton ball held in a forceps fro above the meatus down toward the rectum.
12. With the uncontaminated gloved hand, pick up the catheter and insert it into the meatus 5 cm to 7.5 cm.
13. Do not use force to push the catheter through the urethra into the bladder.
14. Ask the patient to breathe deeply, and rotate the catheter gently if slightly resistance is met as the catheter reaches the external sphincter.
15. Hold the catheter surely while the bladder empties. Do not move the catheter in and out as the bladder drains.
16. When the flow of urine begins to decrease, withdraw the catheter slowly, about 1 cm at a time, until urine barely drips, and then withdraw the catheter.
17. Remove the equipment, and make the patient comfortable in bed. Send the urine specimen to the laboratory promptly or refrigerate it.
18. Record the time of the catheterization, the amount of urine removed, a description of the urine, the patients reaction to the procedure, and your name.

1. Position the patient on his back. The procedure is usually easier when the patients legs are together. Drape the patient so that only the area around the penis is exposed.
2. Place the catheter set on or next to the patients legs.
3. Generously lubricate the catheter for about 15 cm to 18 cm, being careful not to plug the eyes in the catheter.
4. Lift the penis with one hand, which is then considered contaminated. Cleanse the area at the meatus well with cotton balls held with a forceps in a circular motion.
5. Pull the penis with gentle traction straight up with the fingers on the sides of the penis. Slightly pinch the end of the penis, and insert the catheter for 15 cm to 20 cm.
6. Do not use force to introduce the catheter. If the catheter resists entry, ask the patient to deep breathly, and rotate the catheter slightly.
7. Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder.
8. Connect the catheter to the drainage tubing and drainage bag if not already connected.
9. Tape the catheter along the anterior aspect of the thigh.
10. Hang the drainage bag on the frame of the bed below the level of the bladder.

Administering medications through a feeding tube provides an alternative route for administration of medications to the patient who cannot take anything by mouth and has a nasogastric, nasoenteric, or gastrostomy tube in place.

Preparations:
● Check prescriber’s order to verify medication orders.
● Use the five “rights” of drug administration.
● Check with the pharmacist to see if the patient’s medication comes in a liquid form, because these are less likely to cause tube obstruction.
● Determine if the nasogastric tube or gastric tube is in place

Special Considerations
Elderly Patient
• Check level of consciousness.
• Check for aspiration.
• Place in Fowler’s position (30 to 45 degrees) before and after feeding to prevent aspiration.

Pediatric Patient
• Because of the small size of the feeding tube, use only medications that come in a liquid preparation to prevent occlusion.
• Be sure children are in a high Fowler’s or upright position to prevent aspiration during administration.
• Position an infant in a prone or side-lying position for 30 minutes to 1 hour following medication administration.

Relevant Nursing Diagnoses:
● Altered nutrition: less than body requirements related to anorexia and/or failure to thrive
● Self-care deficit related to impaired swallowing and physical mobility
● Ineffective infant feeding pattern related to premature birth and underdeveloped sucking reflex

Expected Outcomes:
● Medications will be administered safely and on time according to physician’s order
● Desired effects from the medication (e.g., relief or pain or decrease in body temperature) will occur
● The feeding tube will remain patent

Equipments and supplies:
● Medication prepared and ready for insertion through the feeding tube according to physician’s orders
● Water for diluting and flushing the feeding tube 60-mL catheter-tip syringe
● Clean gloves

Implementation and Rationale:
1. Review prescriber’s orders.
Determine medications and route to be administered to patient.
2. Gather all equipment before administering the medications.
Saves time and allows efficiency in the medication administration.
3. Stop the tube feeding if medication is to be given on an empty stomach.
Some medications are not absorbed if taken with food or other medications.
4. Prepare each medication separately.
Maintains discrete identity of each medication. If, for some reason, a medication must be withheld, it can be easily identified.
5. Check to determine if medications can be crushed.
Enteric-coated, sustained-action, buccal, and sublingual medications should never be crushed, as doing so alters the absorbability of the medication or yields a toxic dose of the medication.
6. Dilute crushed tablet or powder from a capsule in 30-mL warm water.
Facilitates easier flow of medications through the tube, and cold water may cause patient discomfort.
7. Don nonsterile gloves.
Reduces transmission of microorganisms.
8. Always check and confirm NG tube placement before administering the medications.
Tube must be placed in the correct position to avoid aspiration.
9. Check residual volume, return residual, and flush NG tube.
Validates gastric capacity for receiving medications and flush solution.
10. Flush the tube with 15 to 30 mL of water before administering medications.
Determines tube patency and reduces the risk for obstructing the feeding tube.
11. Disconnect NG tube from the feeding tube, maintaining asepsis of the connecting adapter.
Reduces transmission of infectious organisms.
12. If several medications are being given, administer each one separately using gravity.
Allows identification of each medication given.
13. Flush tube with 15 to 30 mL water after each medication.
Reduces risk for tube obstruction.
14. Restart tube feeding.
Continues nutrition feeding.

Evaluation and Follow-up Activities
● Note if patient gags or coughs
● Patient verbalizes no gastric discomfort
● Patient will exhibit desired effects from the medication
● The NG tube remains patent