IMBALANCED NUTRITION; LESS THAN BODY REQUIREMENT R/T INSUFFICIENT INTAKE OF FOOD RICH IN POTASSIUM AND INTESTINAL DISTURBANCES

ASSESSMENT NURSING DIAGNOSIS S: O: The pt manifested: Low plasma level (2.73 meqs/L) BMI (16.56) Presence of stoma in the right lower quadrant of the abdomen The pt may manifest: Muscle weakness Fatigue Fall, injury, seizures IMBALANCED NUTRITION; LESS THAN BODY REQUIREMENT R/T INSUFFICIENT INTAKE OF FOOD RICH IN POTASSIUM AND INTESTINAL DISTURBANCES SCIENTIFIC EXPLANATION Nutritional deficiencies primarily gastrointestinal the prior Short Term: -after 3 hours of interventions the will Monitor and record vital of signs To determine interventions needed by the client Determining precipitating factors the will Identification and management of underlying cause is essential to recovery These may limit factors to condition To obtain baseline data affects nursing OBJECTIVES NURSING INTERVENTIONS Establish rapport To gain clients trust and cooperation RATIONALE EXPECTED OUTCOME Short Term: -after 3 hours of nursing interventions patient verbalize understanding causative and of factors to the shall

disorder or due to patient procedures verbalize and in after understanding the causative

surgeries, is

case of the pt, she and required

necessary Assess general

necessary

to interventions

interventions nutrition. Long Term:

empty the bowel promote optimum and be placed on nutrition. low for residue several diet days Long Term:

promote optimum

before the surgery -after 8 hours of then nothing by nursing mouth result much her so as a interventions nutritional patient likely behaviour

-after 8 hours of nursing interventions patient demonstrate behaviour changes to regain weight from BMI of the shall

status of the pt is demonstrate affected including changes to regain plasma weight from BMI of Assess ability to

potassium level.

16.56 to 18.

chew, taste and swallow

clients ability to ingest food and reducing desire to eat

16.56 to 18.

Auscultate bowel sounds

Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea which may affect choice of diet/route

Weigh as indicated, evaluate weight in terms of premorbid weight compare serial weights and anthropometri c measures

Indicator of nutritional needs and adequacy of intake

 Plan diet with client and SO, incorporating foods that clients want or food from home

Including the pt in planning gives a sense of control of environment and may enhance intake

Encouraged small frequent meals and snacks of nutritionally dense and non-acidic foods Discussed the importance of adequate nutrition especially fluids, protein, vit.C, vit.B, iron

Fulfilling cravings for desired food may also improve intake

These provide the pt information on how nutrition could elevate her chances of faster recovery

calories and potassium rich foods Instructed the pt to limit foods that include nausea and vomiting, avoid serving very hot and spicy foods Schedule medications between meals if tolerated and limit fluid intake with meals unless fluid has nutritional value Keep strict It is necessary Gastric fullness diminishes appetite and food intake To diminish gastric irritants that may cause client to be reluctant to eat

documentatio n of intake output and calorie count Dependent: Administer medications as indicated and ordered for example antiemetics

to make an accurate nutritional assessment

Reduces incidence of nausea and vomiting possibly enhancing oral intake

Administer vitamin and mineral supplements as ordered by the physician Interdependent: In

To increase nutritional intake

To provide

collaboration with the dietician, determine number of calories required to provide adequate nutrition and realistic weight gain

adequate nutrition and realistic weight gain

IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS ASSESSMENT NURSING DIAGNOSIS S: O: The pt manifested: Presence of stoma in the right lower quadrant of the abdomen The pt may manifest: Pain, itchiness swelling of the skin around the stoma infection IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS colostomy

colostomy OBJECTIVES NURSING INTERVENTIONS Establish rapport To gain clients trust and cooperation the will Monitor and in and Assess general condition To determine interventions needed by the are Long Term: Assess skin, the will selfAEB stoma noted color, turgor sensation; described and measured stoma and observed changes client Establish comparative baseline providing opportunity for timely intervention Long Term: -after 2 days of nursing interventions patient demonstrate increased esteem changing pouch independently selfAEB stoma the shall record vital signs To obtain baseline data RATIONALE EXPECTED OUTCOME Short Term: -after 2 hours of nursing interventions patient participate prevention measures treatment program. and the shall in

SCIENTIFIC EXPLANATION

A colostomy is a Short Term: surgical procedure -after 2 hours of that nursing

brings a portion of interventions the large intestine patient through carry out the participate feces measures abdominal wall to prevention out of the body. In treatment the case of the pt program. temporary colostomy

created to divert -after 2 days of stool from injured nursing or portion large diseased interventions of the patient intestine, demonstrate

allowing rest and increase healing. It is done esteem by accurate changing of pouch depiction

colorectal surgery independently

beginning with a and midline incision, timely then colon is cut healing. to allow insertion of a catheter, the skin then and are tissues closed called

promote Instruct family wound to maintain clean and dry clothes preferably cotton fabric

Skin friction caused by stiff or rough clothes leads to irritation and increases risk for infection

and timely healing.

promote wound

around the new opening stoma. Instruct the pt that the peristomal area should be cleaned well with a mild soap and dried before the new pouch is applied Instruct the pt that the pouch should be change every 4-5 days or when leakage To increase pts knowledge on proper ostomy care To provide proper ostomy care and prevent complications

occurs Teach the pt to The client empty the pouch when it is about half full and teach on how to clean out the pouch properly when emptying it Discuss the importance of adequate nutrition especially fluids, protein, vit.C, vit.B, iron calories and potassium rich foods Instruct the pt Necessary to should demonstrate the ability to empty and change the pouch independently before being discharge These provide the pt information on how nutrition could elevate her chances of faster recovery

in stoma assessment and provided mechanism for documenting

gather more data concerning the pt condition thus, identifying skin problem and promoting selfesteem

Discuss pain control if needed

To help pt coop towards proper pain management, thus minimizing suffering

RISK FOR INJURY R/T PRESENCE OF STOMA ASSESSMENT NURSING DIAGNOSIS S: O: The pt manifested: Presence of stoma in the right lower quadrant of the abdomen Low potassium level (2.73 meqs/L) The pt may manifest: Muscle weakness Falls and seizures RISK FOR INJURY R/T PRESENCE OF STOMA HYPOKALEMIA

HYPOKALEMIA SCIENTIFIC EXPLANATION Because potassium needed normal conduction muscle low potassium Short Term: is -after 4 hours of for nursing nerve interventions and patient function, demonstrate plasma behaviours to level reduce risk factors To determine interventions needed by the client Identification and management of underlying cause is essential to recovery To prevent Long Term: -after 1 week of Determining the and level the precipitating factors nursing interventions patient free and shall from the be injury condition the will Monitor and record vital signs To obtain baseline data OBJECTIVES NURSING INTERVENTIONS Establish rapport To gain clients trust and cooperation RATIONALE EXPECTED OUTCOME Short Term: -after 4 hours of nursing interventions patient demonstrate behaviours to reduce risk factors and protect self from injury the shall

often lead to falls and protect self Assess general and seizures due from injury. to the procedures prior is and required after Long Term: to nursing colostomy, the pt -after 1 week of empty the bowel interventions low for residue several diet from injury reach

and be placed on patient will be free days potassium

potassium

before the surgery will mouth result so as a low

level shall reach the normal range

then nothing by normal range. Ascertain

potassium level is caused decrease intake. by food

knowledge of safety needs/ injury prevention and motivation Put the bed on lowest position

injury from home

To prevent risk for falls To meet the needs without injuries

Develop plan of care within the family to meet pts needs Make sure before the pt walks, clear the path of obstacles and place nonslippery shoes/slipper Discuss the

To prevent injury and falls

These provide

importance of adequate nutrition especially fluids, protein, vit.C, vit.B, iron calories and potassium rich foods DEPENDENT: Administer or give oral/iv potassium as prescribed ensuring that it is diluted in IV fluids it cant be given as IV push INTERDEPENDENT: Notify the

the pt information on how nutrition could elevate her chances of faster recovery

To increase plasma potassium level of the body

To allow more

physician if signs of hypokalemia persist or worsen or during the administration of IV potassium consult the physician if the clients urine is less than 0.5 ml/kg/hr for 2 consecutive hours if signs of impaired pheripheral tissue perfusion is present

accurate interventions to the pt

RISK FOR INFECTION R/T DISRUPTED SKIN INTEGRITY AFTER SURGERY AND PRESENCE OF STOMA ASSESSMENT NURSING DIAGNOSIS S: O: The pt manifested: Presence of stoma in the right lower quadrant of the abdomen Dry and intact midline incision of the abdomen for about 56 inches Presence of transverse cut due to CS Incease RISK FOR INFECTION R/T DISRUPTED SKIN INTEGRITY AFTER SURGERY AND PRESENCE OF STOMA SCIENTIFIC EXPLANATION The skin is the first Short Term: line the defence body. of -after 3 hours of Any nursing the will Monitor and record vital signs To determine interventions needed by the client Long Term: -after 2 days of Note risk the do on factors of having infection in the incision site and stoma To help the client identify the present risk factors that lead to infection To help the pt modify or avoid nursing interventions how to the do on patient shall learn interventions To obtain baseline data OBJECTIVES NURSING INTERVENTIONS Establish rapport To gain clients trust and cooperation RATIONALE EXPECTED OUTCOME Short Term: -after 3 hours of nursing interventions patient demonstrate techniques/ lifestyle condition changes to promote safe environment. the shall

disruption in the interventions skin integrity may patient act on a portal of demonstrate entry opportunistic microorganisms from environment. the occurs, microorganisms can blood. to the inhibit This As by techniques/ lifestyle

changes

to promote safe Assess general

the environment. healing Long Term: -after 2 days of nursing the interventions may how to

soiled stained with patient will learn cause interruption interventions

healing how to prevent or

how to prevent or reduce the risk of infection promote and timely

process and can reduce the risk of cause infection on infection the operation site promote and Make health timely teachings in

WBC count (11.6 The pt may manifest: Fever Pain, itchiness and swelling over the peristomal skin/incision area Redness over the incision site /L)

failure to observe wound healing. good hygiene predispose person infection. personal can a to

identification of environmental risk factors that could lead to infection

environmental factors that could prevent infection

wound healing.

Stress proper hand hygiene among all caregivers, SO and to the pt Monitor pts visitors

A first line defence against infection

To limit exposure thus reduce contamination

Recommend routine or preoperative body showers Instruct family to maintain

To reduce bacterial colonizaon

Skin friction caused by stiff or

clean and dry clothes preferably cotton fabric Instruct the pt that the peristomal area should be cleaned well with a mild soap and dried before the new pouch is applied

rough clothes leads to irritation and increases risk for infection To provide proper ostomy care and prevent complications

Instruct the pt that the pouch should be change every 4-5 days or when leakage occurs

To increase pts knowledge on proper ostomy care

 Teach the pt to empty the pouch when it is about half full and teach on how to clean out the pouch properly when emptying it

The client should demonstrate the ability to empty and change the pouch independently before being discharge

Discuss the importance of adequate nutrition especially fluids, protein, vit.C, vit.B, iron calories and potassium rich foods

These provide the pt information on how nutrition could elevate her chances of faster recovery

DISTURBED BODY IMAGE R/T BIOPHYSICAL ASSESSMENT NURSING DIAGNOSIS S: O: The pt manifested: Presence of stoma in the right lower quadrant of the abdomen Dry and intact midline incision of the abdomen for about 5-6 inches Naming changed body part or function BMI of 16.56 (underweight) DISTURBED BODY IMAGE R/T BIOPHYSICAL COLOSTOMY

COLOSTOMY SCIENTIFIC EXPLANATION The client with Short Term: faces -after 5 hours of and interventions the is able to verbalize a understanding of has body image Assess general or Long Term: condition To determine interventions needed by the client The extent of response is more related to the value of importance the pt places on the Long Term: -after 2 days of nursing interventions the Assess perception of change in structure or function of body part patient shall demonstrate and enhance body image and selfesteem AEB ability to look at/ talk about and care for actual Monitor and record vital signs OBJECTIVES NURSING INTERVENTIONS Establish rapport To gain clients trust and cooperation To obtain baseline data RATIONALE EXPECTED OUTCOME Short Term: -after 5 hours of nursing interventions the patient shall be able to verbalize understanding of body image changes.

ostomy concept body the person /perceived structure

alterations in self- nursing body image. This patient will be image attitude

about the actual changes.

function of all or -after 2 days of part of the body. nursing This attitude is interventions the dynamic and is patient will altered other an through demonstrate and with enhance body people image and selfimportant ability to look at/ Body care for actual interaction

and situations as esteem AEB part of ones self talk about and concept.

image have profound view

altered body

part/function than actual value Assess perceived impact of change on activities of daily living social behaviour and personal responsibilities Evaluate level of pts knowledge of and anxiety r/t situation; observe emotional changes It may indicate acceptance or nonacceptance of situation Note signs of grieving/ indicators of severe depression To evaluate need for counselling and/or medications To determined how the pt act to changes

altered body part/function.

disturbance can part/function. impact on how individual their overall self.

 Determine ethnic background and cultural perceptions and considerations

May influence how individual deals with what happened

Observe interaction of client with SOs

Distortions in body image may be unconsciously reinforced by family members and/ or secondary gain issues may interfere with the progress

Establish therapeutic Provides nurse-client relationship opportunities for listening to

conveying an attitude of caring and developing trust acknowledge the individual as someone worthwhile Encourage verbalizations of and role play anticipated conflicts Encourage the client to use denial without participating Help the client to select and use clothing/make up

concerns and questions

To enhance handling of potential situations To begin incorporate changes into body image To minimize body changes and enhance appearance

Provide information

To allow

at clients level of acceptance and is small pieces, clarify misconception Begin counselling/ other therapies(biofeedb ack/ relaxation

easier assimilations

To provide early/ ongoing sources of support

Discuss the importance of adequate nutrition especially fluids, protein, vit.C, vit.B, iron calories and potassium rich foods

These provide the pt information on how nutrition could elevate her chances of faster recovery