Patient Data

 

Review H and P, nurse's notes, flow sheet, and prescriptions.

Click to mark whether the assessment finding represents a therapeutic result of the bisacodyl administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Therapeutic Result:

• Semifluid stool

Non-therapeutic Side Effect:

• Non-blanchable red area
• Sinus tachycardia
• Burning sensation

Unrelated Finding:

• Pain rating 2 on pain scale of 0 to 10
• Itching in legs
• Blood pressure 135/81 mm Hg

Rationale:

• Non-blanchable red area: A non-blanchable red area indicates localized skin damage and early pressure injury. It likely results from immobility and pressure near the buttock area, especially in a client on strict bedrest, rather than an effect of bisacodyl.
• Pain rating 2 on pain scale of 0 to 10: The lower pain rating reflects effective pain management after receiving analgesics. It is a measure of comfort but not directly influenced by the administration of bisacodyl, which targets bowel function.
• Sinus tachycardia: Sinus tachycardia can occur due to pain, stress, mild dehydration from increased bowel activity, or systemic response to immobility. It is not a typical response to bisacodyl use and requires further clinical monitoring.
• Itching in legs: Itching is most likely related to nerve irritation, healing wounds, or dry skin from immobility rather than gastrointestinal effects. Bisacodyl does not commonly cause peripheral itching.
• Blood pressure 135/81 mm Hg: Blood pressure is within a stable range and reflects the client’s cardiovascular status. It is not directly connected to bisacodyl administration or its gastrointestinal actions.
• Semifluid stool: The semifluid stool is the intended therapeutic effect of bisacodyl, which stimulates peristalsis to promote bowel movement. This outcome shows the medication worked appropriately for constipation management.
• Burning sensation: The burning sensation around the anus is a known side effect of rectal bisacodyl administration. Local irritation of the rectal mucosa can occur after suppository use, especially with frequent bowel movements.

A. Hyperglycemia: While systemic corticosteroids can cause hyperglycemia, inhaled corticosteroids like fluticasone have minimal systemic absorption and rarely lead to significant blood sugar elevations unless used at very high doses over a long time.

B. Dehydration: Dehydration is not a known side effect of fluticasone. This medication acts locally in the respiratory tract and does not impact overall fluid balance significantly.

C. Dry mouth: Inhaled corticosteroids like fluticasone can cause dry mouth or throat irritation due to reduced salivary flow and local mucosal dryness. Clients should be instructed to rinse their mouth after use to minimize discomfort.

D. Oral candidiasis: Oral candidiasis (thrush) is a common side effect of inhaled corticosteroids because the steroid can suppress local immune responses, allowing fungal overgrowth in the mouth. Rinsing the mouth after each inhalation helps prevent this complication.

E. Hypoxia: Fluticasone improves airway inflammation and reduces the risk of hypoxia by enhancing lung function. It does not cause or worsen hypoxia as a side effect.

F. Adrenal suppression: Although rare with low-dose inhaled steroids, adrenal suppression can occur with long-term, high-dose use due to absorption of corticosteroids into the bloodstream. Monitoring and using the lowest effective dose help minimize this risk.

G. Hyperkalemia: Fluticasone does not significantly affect potassium levels. Hyperkalemia is not a recognized side effect of inhaled corticosteroids.