Polypharmacy Case Study Assessment

Polypharmacy Case Study

Student Name
Institution
Course Title
Instructor
Due Date

Polypharmacy Case Study
Patient Assessment
Mrs. Davis is alert and oriented to person, time, and place. Her mental status is intact. She is well-groomed and appropriate for the weather. She has an abnormal gait leaning towards her left side but can ambulate with assistance. She also has weaknesses in the left lower and upper limbs. She has no facial droop with normal vision, swallowing, and speech. Her abdomen is distended, firm, and with mild tenderness on palpation. She has not had bowel movements for the last three days. Bowel sounds at 6 per minute. No flank pain on palpation. She has a scar in the lumbar region. The spinal cord is well aligned, with no deformities. The sacral region is reddened and warm to touch with slight tenderness on palpation, rating 4/10. The capillary refill at 3 seconds, no scleral parlor, intact skin, no rashes, no edema noted. Pulses are present with adequate strength and rate. Vital signs, pulse rate 12 beats/minute, blood pressure 124/74mmHg, per minute, temperature 970 F, and SPO2, 96%. No recent lab results.
Question 1
My nursing assessment would focus on the patients chief complaints. I will conduct a focused evaluation of the back, abdomen, and neurological system. I will assess the intensity, severity, aggravating, and relieving factors for the pain.
Question 2
What aggravates the pain?
What is the main component of your daily meal?
Is the stool bloody?
How much water do you take daily?
Does the back pain interfere with your daily activities?
Nursing Diagnosis
Nursing Diagnosis
Constipation related to side effects of narcotics used for back pain management as evidenced by patient verbalization of difficulty passing stools, not passing stool for three days, passing hard stools, distended abdomen, and laxatives.
Goal
Short-term goal: to relieve constipation within 8 hours of nursing care.
: To restore regular bowel habits within one week of nursing care.
Nursing Interventions
I will administer milk of magnesia, 30 ml orally. Milk of magnesia is a laxative that softens stools (Krogh et al., 2017). The drug will promote comfort and relieve abdominal tenderness.
I will educate the patient on dietary changes such as eating foods high in fiber, drinking adequate water, and avoiding salt. A high fiber diet improves the bulk in the stool (Krogh et al., 2017). Fibre also attracts water that softens stool for easy elimination.
I will also educate the patient on the importance of exercise. Exercises aid in bowel movements by increasing the motility of the gastrointestinal tract (Krogh et al., 2017). Exercises also lower the transit time.
Situation, Background, Assessment, and Recommendation (SBAR)
Ms. Davis 81 years old female with intermittent abdominal and back pain rating of 4/10. The patient has a history of stroke and vertebral fracture, which resulted in the current back pin. The patient takes PO Acetaminophen 325 mg PRN for mild to moderate pain and Narco, two for moderate to severe pain. From my assessment, the abdomen is distended and firm with mild tenderness on palpation. The vital signs are also within the normal range. I think the problem is constipation. I have administered a laxative previously prescribed to the patient. I recommend that a review of the current medications the patient is taking is done.

References
Krogh, K., Chiarioni, G., & Whitehead, W. (2017). Management of chronic constipation in adults.United European Gastroenterology Journal,5(4), 465472. https://doi.org/10.1177/2050640616663439