Video Case Study - Nursing Care for Constipation

Nurse Kelly works at a primary care office and is caring for Francesca, an 83-year-old who is experiencing constipation.

In collaboration with the registered nurse, RN Evan, Nurse Kelly goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Francesca’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Kelly recognizes important cues, including Francesca’s vital signs, which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respirations 18 breaths per minute, and blood pressure 116/64 mmHg.

Francesca denies pain, but states her abdomen feels full and distended. When asked about her last bowel movement, Francesca replies that she hasn’t had a bowel movement in 3 days, and normally has 2 to 3 hard, lumpy bowel movements each week.

Nurse Kelly listens to Francesca’s bowel sounds, which are hypoactive in all four quadrants. Next, Nurse Kelly analyzes these cues.

She reviews the electronic health record, or EHR, and sees that Francesca takes a diuretic which can increase her risk for constipation due to the elimination of excess body fluids.

Then, she gathers information from Francesca about other risk factors for constipation. Nurse Kelly: Francesca, how would you describe your activity level?

Francesca: I walk around my house, but that’s it. Sometimes, my knees bother me, and I can’t get around that well.

So, I guess I sit around a lot. Nurse Kelly: Okay, and how would you describe your fluid intake and diet?

Francesca: I try not to drink too much water because then I have to go to the bathroom all the time, especially with my water pill.

As for my diet, I mostly have my meals delivered. I really like the frozen dinners they send me.

Nurse Kelly realizes that Francesca has several risk factors for constipation. She has a mostly sedentary lifestyle, and because of Francesca’s age, her gastrointestinal motility is slower.

Also, Francesca is more prone to dehydration, since she limits her water intake and may not be prompted to drink due to an age-related decrease in thirst sensation.

Nurse Kelly realizes that Francesca needs effective bowel elimination. Now, using the information she has gathered, along with Francesca’s medical history, Nurse Kelly reports her findings to RN Evan, and they choose a priority hypothesis of altered bowel elimination.

They generate solutions to address Francesca’s constipation that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Francesca will report having a bowel movement within 2 days.

Nurse Kelly then takes action to implement these solutions. First, RN Evan speaks with the health care provider who orders an osmotic laxative for Francesca.

RN Evan teaches Francesca about her diagnosis and medication; and Nurse Kelly reenters the room to review the plan of care.

Nurse Kelly: So, Francesca, I’d like to review the plan for resolving your constipation. What new things will you be doing?

Francesca: Well, I’m going to start taking the medication. And I’m also planning to take a walk around my block in the mornings after breakfast with my grandson.

He can help me if my knees start to hurt. Nurse Kelly: Those are great ideas!

You can start taking your medication tomorrow morning with your breakfast. What types of foods do you plan to eat to help with your symptoms?

Francesca: I usually have toast for breakfast, but RN Evan told me that oatmeal is a better choice since it’s high in fiber.

He also told me that frozen dinners don’t have a lot of fiber, so I’m going to have my grandson bring me more foods like apples and frozen vegetables.

Nurse Kelly: That sounds great! Now, I know it can be frustrating to have to urinate more often, but make sure to also increase your fluid intake.

Sometimes drinking warm liquids, like herbal tea, can help you have a bowel movement too. Francesca: Okay, I do like herbal tea.

At the end of the appointment, Nurse Kelly walks Francesca out to the front desk and tells her that she will call Francesca to follow-up.

Two days later, Nurse Kelly calls Francesca to evaluate the outcome of her actions. Nurse Kelly: Hi, Francesca, it’s Nurse Kelly from your health care provider’s office.

I’m checking to see how you’ve been feeling. Francesca: I’ve been taking that medication once a day, and today I finally had a large, soft bowel movement.

I feel much better! Nurse Kelly: That’s great.

Have you been able to include more fiber and fluids in your diet? Francesca: Yes.

Today I made myself some oatmeal and had herbal tea to drink in the morning, which seemed to help. Nurse Kelly: Good.

Keep up the good work! Alright, as a quick recap… Nurse Kelly recognized and analyzed cues related to Francesca’s altered bowel elimination and, in collaboration with RN Evan, prioritized hypotheses and generated solutions to address this problem.

Nurse Kelly and RN Evan then implemented pharmacologic and nonpharmacologic measures and evaluated Francesca's outcomes and compared them to the expected outcome.

Since Francesca had a bowel movement within 2 days, Nurse Kelly determined that the plan of care was