Patient initials: T. E

Date of care:3/27/2022

Background: Ms. T.E is a 43-year-old Hispanic female. She has had a past medical history of constipation. She has been treated for abdominal aortic aneurysms in the past. The patient’s medical history also includes treatment and provision of supplements that will aid indigestion and passing stool.

Reason for visit or hospitalization: Fecal Impaction, constipation, vomiting

Pertinent social history, including living situation, for discharge planning or case management purposes:

Ms. T. E is a 43-year-old Hispanic woman with a complaint of fecaloma (fecal impaction), N/V, bloating, constipation, bowel obstruction, and excessive gas passing. The patient works with CPS. The patient is A&O X 4, patient reports pain with difficulty passing stool. The patient has a history of smoking and drinking and rarely drinks fluid during meals. The patient states she loves fast foods from restaurants and smokes cigarettes. The patient states she consumed some amount of alcohol prior to the commencement of pain, nausea, and vomiting feeling and consequently solve with medications.

S: T.E is a 43-year-old female with complaints of severe belly cramping. She is alert and oriented X4. The patient states she is experiencing nausea and has vomited severally since she’s been hospitalized. She has also complained of abdominal bloating and intense constipation that comes with pain. The patient complains that she is experiencing rectal bleeding with a large lump of dry, hard stool that stays stuck in the rectum, making it hard for her to pass stool. She has a past medical history of hypoxic brain injury.

O: On this day, the patient’s vital signs data from the physical assessment include lab blood data, blood pressure at 120/78, the pulse rate at 69 beats per minute, and respiratory rate is at 16 beats per minute. No wheezing sounds were present from her lungs and throat. Important objective data include bloated and distended belly accompanied by sounds. The skin is moist and intact has no presence of rashes but is pale around the belly area. The patient was able to pass little urine during the assessment.

A: The patient primary medical diagnosis is fecaloma. This is happening due to constipation and vomiting that the patient is experiencing. The patient’s vital signs assessment data indicate the patient is still within normal blood pressure range with no difficulty in breathing present.

Nursing diagnoses include (i) belly cramping/bowel elimination impairment. (ii) abdominal pain and back pain causing discomfort. (iii) difficulty while urinating and rectal bleeding the treatment goal for the patient is to encourage a lot of fluids for bowel elimination. And the impairment is to facilitate bowel excretion and make sure the patient is comfortable. The first goal is to reduce fecal impaction and abdominal pain. The nursing goal for difficulty in urination is to provide intervention to improve urination by offering oral rehydration therapy and encouraging patients to ambulate. Lastly, providing digital disimpaction and enema procedures to prevent blood in stool would also be a goal to be taken to facilitate care for the patient.

P: Plan of care includes conducting an X-ray at the patient’s belly to spot the position of the fecal impaction while also patient would undergo an enema procedure to facilitate the passing of stool. In addition, the patient would be administered laxatives to ease impaction and prevent injuries to colon walls that lead to bleeding.

The first nursing priority and intervention would be to offer oral rehydration therapy following an enema test to prevent fecal impaction. The second priority intervention will be to encourage a fiber diet and supplements to the patient to prevent defection. In addition, pain medications will be provided to help ease patient pain.

Case management or discharge planning needs.

The discharge plan includes adequate intake of fiber-rich foods, efficient fluid intake, and physical activities.

Patient education needs

Ms. T.E needs patient education on the administration of stool softeners such as Psyllium husk or Colace, dietary needs including food rich in fibers, regular bowel elimination, and taking of fluids including water to prevent dehydration.

Psychosocial, spiritual, and/or family support needs

The psychosocial needs for the patient would include supportive care to overcome fear and anxiety as well as privacy and spiritual needs.