Azusa Pacific University

School of Nursing
ELM Program
Summer 2016
Nursing Care Plan
Student Name: Raquel McCarthy
Pt. initial, gender & age: R.M., Male, age: 2 y.o.10 m.o., 13kg
Admit Date: 7/20/16
Admitting diagnosis: Acute abdominal pain
Date of Care: 7/21/16
ASSESSMENT DATA: (10 points)
1. History of Present Problem: Patient and mother presented to the ED with complaints of abdominal pain,
abdominal distention, and decreased PO intake. Patients mother denied emesis. Mother reported that the patient
woke up at 8am complaining of pain. She reported that he was curled up in a ball and refusing to walk and his
abdomen was sensitive to touch. In the ED, patient was passing gas but not stool. ED report stated that the patient
appeared to be uncomfortable with soft ,yet distended abdomen.
2. Past Medical History: Constipation
What is the relationship of your patients past medical history (PMH) and current medication? Which
medications treat which conditions?
PMH
1. Constipation

Home
Medications
1. Soap suds
enema

Pharm. Classification

Expected Outcome

1. Large volume enema.

1. Stimulates peristalsis
through intestinal irritation.

Reference: Shannon, M.T., Shields, K.M., Stang, C.L. & Wilson, B.A. (2015). Nurses Drug Guide. (Pp. 235-543).
Prentice Hall Health. Pearson Education. Boston, MA.
Patient Care Begins: (10 points)
Vital Signs:
Time

Temp F/C

Pulse (apical/radial)

Resp/min

BP in mmHg
Right or Left

Pulse Ox % Room air/oxygen

& delivery

2251

37.3 C

120 radial

22

140/70 LL

100% RA

0207

37.0 C

104 radial

18

114/47 LL

99% RA

0830

37.0 C

100 radial

20

108/50 LL

96% RA

1445

36.7C

106 apical

22

139/82 LL

100% RA

Pain Assessment:
Time

Pain Tool
Used:

Pain
Rating

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Pain Description
(OLDCART)

Functional
Pain Goal

Pain Medication
(or other care)

Response To
Intervention

Numeric,
FLACC
Baker/Wo
ng

0-10

Onset, Location,
Duration,
Characteristic,
Aggravating,
Relieving, Treatment

0-10

Include name,
dose, route, &
frequency

0207

FLACC

n/a

n/a

n/a

n/a

0830

FLACC

n/a

n/a

n/a

n/a

1435

FLACC

n/a

n/a

n/a

n/a

What vital sign data are relevant that must be recognized as clinically significant?
Relevant Vital Sign Data:
Clinical Significance:
1. Temperature
1. Rule out infections like peritonitis, or sepsis.
2. Respiratory rate and pattern

2. Patients with abdominal pain take shallow, rapid breaths

to reduce pain

3. Pulse and blood pressure

3. Pulse and blood pressure are elevated when pain is present
Reference:
Rull, G. (2013). Abdominal pain in children. Patient. Retrieved from http://patient.info/doctor/abdominal-pain-inchildren
General Appearance:
Neuro:
Cardio-Vascular:

Physical Assessment on day of care:

Well kept, clean and well nourished. Affect is appropriate to situation. Patient does not
appear to be in distress. Negative for fever or activity change.
Patient is alert. Pt is verbal. Pt responds to simple, complex commands/cues. Negative
for seizures. Negative for confusion.
Skin is pink, warm and dry. Capillary refill < 3 seconds all extremities. Heart sounds:
regular rate and rhythm. S1/S2 noted, no murmurs or gallop. Apical pulse: 106 bpm.

Respiratory:

GI:

GU:
Skin:

Musculo-Skeletal:

Quality: Symmetrical expansion, bilateral chest rise, unlabored breathing at rest._

Rate: 22 BPM. Rhythm: Regular.
Right and Left lung: Normal breath sounds. No adventitious sounds present.
Negative for cough.
Bowel sounds: Normoactive all 4 quadrants.
Oral mucosa: intact, moist, pink.
Tongue: midline, pink.
Abdomen: Non-tender, no ascites, non-distended. Symmetrical, no striations present.
Pts mother reports last bowel movement on 7/20/16 after soap suds enema (66mL).
Positive for constipation. Negative for nausea, vomiting, diarrhea.
Pt. wears diaper, pull ups.
Urine character: yellow, clear, transparent.
Positive for decreased urine volume and difficulty urinating.
Skin color normal for ethnicity. Pink. Skin warm, dry, and intact. No lesions, ulcers.
Skin turgor is normal.
Five spider bites noted on right forearm, round erythematous patches with fluid-filled
vesicle in center.
Able to follow commands and move upper and lower extremities. Mobile. Full ROM all
extremities.
Negative for myalgias.

Fluids /Nutrition
Diet / Feeding method: Clear liquid diet. No red,
purple or blue.
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IV solution /rate: D5W 0.45% NaCl IV infusion

premix/ 46mL/hr continuous

NG: 1500mL PEG/electrolytes (Nulytely)

IV site/type: Right forearm

24 hour fluid calculation

Maintenance: 1150 mL Hourly: 48mL/hr
1 times maintenance: 1725 mL Hourly: 72 mL/hr
Growth and Development: (Erikson Piaget, Physical)
Actual Developmental level: The patient meets the
milestones associated with Eriksons adolescent stage of
development as well as Piagets formal operational
stage. He does not have any apparent developmental
delays.

Expected developmental level

Erikson: Autonomy vs. Shame and Doubt. The patient
did not demonstrate a strong sense of autonomy because
he was in a strange environment and wanted to be close
to his mother for comfort. He did however, protest to
getting his vitals taken which demonstrates some sense
of autonomy and control appropriate for this stage of
development.
Piaget: Pre-operational stage. Pretend play is common
but toddlers struggle with logic and seeing things from
the perspective of others. The patient demonstrated
pretend play with trucks and army men.
Spiritual needs: The patient only wanted comfort from
his mother. The patients mother needed a few moments
for herself to eat, make necessary calls and to shower. I
was able to stay with the patient for an hour, so that she
could do the basic things she needed to do.

Play needs: (What did you actually do?) Held and

comforted the patient while his mother left to get
something to eat and make some phone calls. We played
trucks and read books so that he wasnt focused on his
mothers absence.
Family involvement: Mother was at bedside and
actively involved in patient care. Father was absent but
maintained frequent contact by phone.
Reference:
Hockenberry, M. & Wilson, D. (2013) Wongs Essentials of Pediatric Nursing 9th ed. Elsevier Mosby.

What body system(s) will you most thoroughly assess based on the primary/priority concern?
RELEVANT Assessment Data:
Clinical Significance:
Integumentary: Assess integrity of skin
Patient was being given NULYTELY electrolyte solution to
around bottom and anus.
stimulate bowel emptying and is in a diaper so its important to make
sure the skin around his bottom and anus remains intact.
GU: Fluid status and output.
Electrolyte and fluid imbalances can occur with NULYTELY
GI: Monitor for stools, diarrhea.
administration.
Bowel cleansing regimen is being used to alleviate constipation.
Radiology Reports:
What diagnostic results are relevant that must be recognized as clinically significant for the nurse?
Relevant Results:
Clinical Significance:
X-ray
(7/20/16) Circular mass consistent with stool ball.
(7/21/16) NG tube placement at expected location.
CT Scan
none
MRI/Ultrasound
none
Other:
none
Lab Order(s)

Current values:

Complete Blood
Count
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N/H/L
Clinical Significance
for High or Low
results

Previous Results:
If applicable

WBC

15.6 th/uL

Hgb

12.2 g/dL

Hct

39.4%

Platelets

300 th/uL

Neutrophils
Basic Metabolic
Panel
Sodium

5.5 th/uL

Potassium

5.0 mmol/L

Glucose

69 mg/dL

BUN

13mg/dL

Creatinine

0.19 mg/dL

Calcium

9.9 mg/dL

Chloride

104 mmol/L

Other Labs:

No blood gases
performed

140 mmol/L

Trends:
Stable/Improve/wors
e
High value (normal
range: 4.0-12.0
th/uL). May indicate
infection or be the
result of stress/pain.
WNL (normal range:
11.5-14.5g/dL)
WNL (normal range:
33%-43%)
WNL (normal range:
150-300)
WNL
WNL (normal range:
132-143)
WNL (normal range:
3.5-5.0)
WNL (normal range:
60-115).
WNL (normal range:
5-17)
WNL (normal range:
0.10-0.60)
WNL (normal range:
8.8-10.8)
WNL (normal range:
98-108)

*Much of the patients chart was in paper form from the Chula Vista ED he visited before being admitted to Radys.
What lab results are relevant that must be recognized as clinically significant to the nurse?
Relevant
Clinical Significance:
Trends: Improve/worsening/Stable
Labs:
WBCs
15.6 th/uL High value (normal
There is no previous result for comparison.
range: 4.0-12.0 th/uL). May
indicate infection or be the result
of stress/pain. Acute abdominal
pain as the chief complaint
should be investigated and
infection should be ruled out.
Hgb
12.2 g/dL WNL (normal range:
There is no previous result for comparison.
11.5-14.5g/dL). Important to
monitor hemoconcentration when
giving IV fluids to ensure that
adequate perfusion is taking
place.
Hct
39.4% WNL (normal range: 33%- There is no previous result for comparison.
43%). Important to monitor
hemoconcentration when giving
IV fluids to ensure that adequate
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perfusion is taking place.

Current Medications List: Create a list of medications that you GAVE DURING YOUR SHIFT: (Reference
Needed)
Name of Medication given:
Dose: 1500 mL
Nulytely Solution (Polyethylene
glycol/electrolytes)

Route: NG

Rate: 25 mL/kg/hr

Classification:

Hyperosmotic laxative

Action:

Bowelcleansing.Causes the colon to produce watery stool to empty bowels.

Safe dose range for age/wt:

25 mL/kg/hr

Rational for use in THIS patient:

Constipation and obstruction.

Desired Effect:

Bowelcleansing.

Side Effects:

Bloated feeling, pain in upper abdomen, stomach pain, swelling of abdomen,

vomiting, hunger, nausea.

Toxic Effect:

Serum and fluid chemistry abnormalities, cardiac arrhythmias, seizures, renal

impairment.

Nursing Implications:

Clear liquids only, no red, blue or purple. Monitor patients output, check for
signs of electrolyte or fluid imbalance including monitoring patients cardiac
rate and rhythm to detect cardiac arrhythmias.

Pt/Family teaching needs:

Patient will begin to have runny, watery stools as the medication begins to
work. He should wear a diaper that needs changing frequently and all family
members should use a blanket or chuck pad placing it under the patient while
holding him, to avoid messes.

Reference: Shannon, M.T., Shields, K.M., Stang, C.L. & Wilson, B.A. (2015). Nurses Drug Guide. (Pp. 235-543).
Prentice Hall Health. Pearson Education. Boston, MA.

Name of Medication given:

D5W 0.45% NaCl

Dose: 46mL/hr

Classification:

Isotonic volume expander, Electrolyte replacement.

Action:

Replenishes fluids, calories and electrolytes.

Safe dose range for age/wt:

10mL/kg/hr

Rational for use in THIS patient:

To maintain/replenish water, calories and electrolytes.

Desired Effect:

Hydration.

Side Effects:

Febrile response, infection at site, extravasation, thrombophlebitis.

Toxic Effect:

Hypervolemia, dyspnea and edema.

Nursing Implications:

Monitor IV site for signs of thrombophlebitis, infection or inflammation.

Assess patients fluid status frequently. Monitor input and output.

Pt/Family teaching needs:

IV fluids are given to maintain the patients hydration since he is not able to

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Route: IV

Frequency: continuous

eat right now. They cam also help with softening stool so that it may pass
more easily.
Reference: Shannon, M.T., Shields, K.M., Stang, C.L. & Wilson, B.A. (2015). Nurses Drug Guide. (Pp. 235-543).
Prentice Hall Health. Pearson Education. Boston, MA.
Clinical Reasoning Begins: (20 points):
What is the primary problem that your patient is most likely presenting with? Fecal impaction from
constipation.
In your own words, what is the underlying cause/pathophysiology of this concern? (APA format and MUST be
referenced!)
Constipation in toddlers can be the result of several underlying processes. Among the most common of these is diet,
holding it in, fear of discomfort, change in routine, lack of exercise, and medication (WebMD, 2016). The patients
mother reported that he has been having trouble with potty training and has a history of constipation, therefore he
holds in his stools rather than telling her that he needs to use the toilet. Toddlers will hold it in because they are more
interested in playing or feel embarrassed. During normal defecation, stool enters the rectum causing distention,
which signals the need to defecate (Andrews & Storr, 2011). If this urge is ignored because of inconvenience, the
rectum relaxes and the urge dissipates, thus accommodating more stool (Andrews & Storr, 2011; Heuther &
McCane, 2012). Frequent holding can lead to constipation or impaction.
In some cases, toddlers rebel against toilet training by refusing to go. Toddlers with a history of constipation that
may have had painful bowel movements in the past may hold in stools out of fear that it will hurt again.
Additionally, diet and exercise may play a role. A diet high in processed foods and low in fiber does not help to
move stool along the digestive tract (WebMD, 2016). Fluids also help to make stools softer and easier to pass while
exercise mechanically moves food through the digestive process. Fluids are absorbed by the colon and passed with
the stool. If stool is held in too long, the stool becomes drier and impacted making it too difficult to pass through the
anal canal (Andrews & Storr, 2011). The patients mother may need education on the importance of a healthy, high
fiber diet, fluids, exercise and a frequent toileting schedules.
References:
Andrews, C. N., & Storr, M. (2011). The pathophysiology of chronic constipation. Canadian Journal of
Gastroenterology, 25(Suppl B), 16B21B.
Huether, S.E. &McCance, K.L. (2012). Understanding Pathophysiology (5th ed.). pp. 402. St. Louis, MI: Elsevier
Mosby.
WebMD (2016). Toddler constipation. Childrens Health. Retrieved from
http://www.webmd.com/children/guide/toddler-constipation-causes-treatments#1
Based on your knowledge of pathophysiology of your patients medical problem, which disease likely
developed first that then initiated a domino effect in your patients life?
1.
2.

What PMH problem started first? Patients mother reported that he has a history of constipation and has
been having difficulty with potty training. She states that he will hold in his stools rather than go on the
toilet.
What PMH problem(s) followed as a domino effect?
a) Constipation
b) Fecal impaction

DIAGNOSIS:
What nursing priorities captures the essence of your patients current status and will guide your plan of
care? Provide one long term and one short term goal for each diagnosis: (List each in the form of a NANDA
three-part nursing diagnosis, MUST have a minimum of three (3).
A. Nursing Diagnosis #1: Risk for impaired skin integrity related to moisture as evidenced by diarrhea,
watery stool.
a. Short-term goal: Patient will report altered skin sensation or pain in at risk areas (in diaper) by
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end of shift.
b. Long-term goal: Patient will maintain intact skin including mucous membranes by end of stay.
Nursing Interventions:
Rationale:
Expected Outcome:
Nsg. Dx 1
Assess skin integrity and condition at
least once per shift (head to toe)
looking under diaper.
Keep skin clean and dry changing
soiled linens frequently.
Use a barrier product to reduce risk of
exposure to moisture.

Systemic inspection can

identify impending
problems early.
Moisture promotes skin
breakdown.
The use of a skin
protectant can significantly
decrease skin breakdown
and prevent pressure sore
formation.

Nsg. Dx 3
Assess pain intensity level using an
appropriate, valid and reliable pain
scale based on age, cognitive
development and childs ability to
self-report (FLACC scale).
Determine clients medication use by
obtaining a list of medications the
patient is currently taking.
Use non-pharmacological
interventions to supplement
pharmacological interventions.

A variety of behavioral
observation tools are
available and helpful for
pain recognition in
children under 4.
Accurate medication
reconciliation can prevent
errors related to
interactions, toxicity.
Relaxation, distraction, art
therapies, and imagery
play an important role in
pain management.

Short term: Goal

met. Patient told
mom that he felt
wet and needed

his diaper
changed.

Long term: Goal

partially met. Skin
remained intact at
end of shift but
patient was still
admitted.
A. Nursing Diagnosis #2: Constipation related to functional process of inadequate toileting as evidenced by
patients difficulty with toilet training, fecal impaction.
a. Short-term goal: Patient will pass a soft, formed stool within 1-3 days without straining.
b. Long-term goal: Patients mother will identify measures that prevent or treat constipation by
discharge.
Nsg. Dx 2
Emotions influence GI
Short term: Goal
Consider emotional influences on
function. Difficulties with
not met. Patient is
defecation.
defecation often begin in
being given
childhood during toilet
Nulytely and is
Provide privacy for defecation.
training.
having watery
Instruct patients mother on normal
stools as a result.

Bowel
elimination
is
a
bowel function and the need for
Also, not enough
private
act
and
a
lack
of
adequate fluid and fiber intake,
time has passed to
privacy can hinder
activity, and a defined toileting
evaluate goal.
defecation urge.
pattern.
Long term: Goal
Patients mother can
met. Patients
prevent constipation by
mother verbalized
increasing fiber and fluid
the need for a
intake, encouraging
change in diet and
activity and establishing a
frequent fluids to
toileting schedule.
prevent
constipation.
A. Nursing Diagnosis #3: Acute pain related to injury agents (biological) as evidenced by abdominal
distention, fecal impaction on x-ray.
a. Short-term goal: Patients pain intensity level will be identified using the FLACC scale at
admission.
b. Long-term goal: Patient will demonstrate a decrease in pain-related behaviors by end of stay.

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Short term: Goal

met. FLACC scale
used to quantify
pain on initial
assessment.
Long term: Goal
met. Patient
appears
comfortable and
relaxed. Patient
was able to sleep.
No distress noted.

Reference:
Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidenced Based Guide to Planning Care.
(Pp. 238, 583, & 738). Maryland Heights, MO: Mosby Elsevier.
1.
2.

3.

What is the worst possible/most likely complication to anticipate based on the primary problem?
Chronic constipation can lead to hemorrhoids, anal fissures, or rectal prolapse if the patient strains to expel
the stool.
What nursing assessments will identify this complication EARLY if it develops? Monitoring the patient
while he has a bowel movement is the best way to detect if straining while toileting is occurring. The nurse
is also advised to do frequent, focused assessments of the patients perineal and anal areas to make sure that
fissures, hemorrhoids arent present. This can be performed while assessment of skin integrity is conducted.
What nursing interventions will you initiate if this complication develops? Administration of stool
softeners before a bowl movement is the best way to ensure that complications from straining and the
passage of hard stools doesnt create complications like anal fissures, rectal prolapse or hemorrhoids.
EVALUATIONS: (10 points)

All physicians orders have been implemented that are listed under medical management. Evaluate the
response of your patient to nursing and medical interventions during your shift.
1.

2.
3.

Has the status of your patient improved or not as expected to this point? Patients status has
remained unchanged over my shift. He is receiving Nulytely via NG tube but the medication
has yet to take affect. Bowel evacuation is anticipated but hasnt occurred. The patients pain
has improved from admission. He received a score of 0 on the FLACC scale on the last 3
assessments and was able to nap for 2 hours.
Do your nursing plans/goals and interventions need to be modified in any way after this
evaluation assessment? Explain: No.
What will be the most important discharge/education priorities you will reinforce with their
medical condition to prevent future readmission with the same problem? Explain: Discharge
teaching will include educating the patients mother on proper high fiber diet, avoidance of
processed foods, adequate fluid intake, exercise and monitoring stools/frequency of bowel
movements to intervene early before constipation becomes fecal impaction.

SBAR Report:
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can
adversely impact the care of this patient. You have done an excellent job at this point, now finish strong and provide
an SBAR report to the nurse who will be caring for this patient after you
Situation:
Background:
Assessment:
Recommendation(s):

Patient was admitted with acute abdominal pain, a fecal impaction was found on
x-ray and the physician ordered Nulytely via NG for bowel cleansing. The
Nulytley has yet to take affect.
Patient has a history of constipation and has been having difficulty with potty
training recently. His mother is at the bedside. He is currently still wearing
diapers. Pain is a 0 on FLACC scale.
My assessment is that the patient appears calm and free from pain. He does not
appear to have abdominal cramping indicating a bowel movement is about to
occur.
If you fail to see passage of watery stool in the next hour or two, I would
recommend turning up the rate on the NG tube.

References:
Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidenced Based Guide to Planning Care.
Maryland Heights, MO: Mosby Elsevier.

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Andrews, C. N., & Storr, M. (2011). The pathophysiology of chronic constipation. Canadian Journal of
Gastroenterology, 25(Suppl B), 16B21B.
Huether, S.E. &McCance, K.L. (2012). Understanding Pathophysiology (5th ed.). pp. 402. St. Louis, MI: Elsevier
Mosby.
Hockenberry, M. & Wilson, D. (2013) Wongs Essentials of Pediatric Nursing 9th ed. Elsevier Mosby.
Shannon, M.T., Shields, K.M., Stang, C.L. & Wilson, B.A. (2015). Nurses Drug Guide. (Pp. 235-543). Prentice Hall
Health. Pearson Education. Boston, MA.
WebMD (2016). Toddler constipation. Childrens Health. Retrieved from
http://www.webmd.com/children/guide/toddler-constipation-causes-treatments#1

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