8ncp's for colostomy

29
IMBALANCED NUTRITION; LESS THAN BODY REQUIREMENT R/T INSUFFICIENT INTAKE OF FOOD RICH IN POTASSIUM AND INTESTINAL DISTURBANCES ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME S: ǿ 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 IMBALANCED NUTRITION; LESS THAN BODY REQUIREMENT R/T INSUFFICIENT INTAKE OF FOOD RICH IN POTASSIUM AND INTESTINAL DISTURBANCES Nutritional deficiencies primarily affects gastrointestina l disorder or due to the procedures prior and after surgeries, in the case of the pt, she is required to empty the bowel and be placed on low residue diet for several days Short Term: -after 3 hours of nursing interventions the patient will verbalize understanding of causative factors and necessary interventions to promote optimum nutrition. Long Term: -after 8 hours of nursing Establish rapport Monitor and record vital signs Assess general condition Determining precipitatin g factors To gain client’s trust and cooperation To obtain baseline data To determine intervention s needed by the client Identificati on and management Short Term: -after 3 hours of nursing interventions the patient shall verbalize understanding of causative factors and necessary interventions to promote optimum nutrition. Long Term: -after 8 hours of nursing

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Page 1: 8NCP's for colostomy

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

INTESTINAL DISTURBANCES

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S: ǿ

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

Nutritional

deficiencies

primarily affects

gastrointestinal

disorder or due to

the procedures

prior and after

surgeries, in the

case of the pt,

she is required to

empty the bowel

and be placed on

low residue diet

for several days

before the

surgery then

nothing by mouth

so as a result

nutritional status

of the pt is much

likely affected

including her

Short Term:

-after 3 hours of

nursing

interventions the

patient will

verbalize

understanding of

causative factors

and necessary

interventions to

promote optimum

nutrition.

Long Term:

-after 8 hours of

nursing

interventions the

patient will

demonstrate

behaviour

changes to regain

weight from BMI

Establish

rapport

Monitor and

record vital

signs

Assess

general

condition

Determining

precipitating

factors

To gain

client’s trust

and

cooperation

To obtain

baseline data

To determine

interventions

needed by the

client

Identification

and

management

of underlying

cause is

essential to

recovery

Short Term:

-after 3 hours of

nursing

interventions the

patient shall

verbalize

understanding of

causative factors

and necessary

interventions to

promote optimum

nutrition.

Long Term:

-after 8 hours of

nursing

interventions the

patient shall

demonstrate

behaviour

changes to regain

weight from BMI

Page 2: 8NCP's for colostomy

plasma

potassium level.

of 16.56 to 18. Assess ability

to chew, taste

and swallow

Auscultate

bowel sounds

Weigh as

indicated,

evaluate

weight in

terms of

premorbid

weight

compare serial

weights and

anthropometri

c measures

These may

limit client’s

ability to

ingest food

and reducing

desire to eat

Hypermotility

of intestinal

tract is

common and

is associated

with vomiting

and diarrhea

which may

affect choice

of diet/route

Indicator of

nutritional

needs and

adequacy of

intake

of 16.56 to 18.

Page 3: 8NCP's for colostomy

Plan diet with

client and SO,

incorporating

foods that

client’s want

or food from

home

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 calories

and potassium

Including the

pt in planning

gives a sense

of control of

environment

and may

enhance

intake

Fulfilling

cravings for

desired food

may also

improve

intake

These provide

the pt

information on

how nutrition

could elevate

her chances of

faster

recovery

Page 4: 8NCP's for colostomy

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

documentatio

n of intake

To diminish

gastric

irritants that

may cause

client to be

reluctant to

eat

Gastric

fullness

diminishes

appetite and

food intake

It is necessary

Page 5: 8NCP's for colostomy

output and

calorie count

Dependent:

Administer

medications

as indicated

and ordered

for example

antiemetics

Administer

vitamin and

mineral

supplements

as ordered by

the physician

Interdependent

:

In

collaboration

with the

dietician,

to make an

accurate

nutritional

assessment

Reduces

incidence of

nausea and

vomiting

possibly

enhancing oral

intake

To increase

nutritional

intake

To provide

adequate

nutrition and

Page 6: 8NCP's for colostomy

determine

number of

calories

required to

provide

adequate

nutrition and

realistic

weight gain

realistic

weight gain

IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS 20colostomy

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

Page 7: 8NCP's for colostomy

S: ǿ

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 20

colostomy

A colostomy is a

surgical

procedure that

brings a portion

of the large

intestine through

the abdominal

wall to carry out

feces out of the

body. In the case

of the pt

temporary

colostomy are

created to divert

stool from injured

or diseased

portion of the

large intestine,

allowing rest and

healing. It is done

by accurate

depiction of

colorectal surgery

beginning with a

midline incision,

then colon is cut

to allow insertion

Short Term:

-after 2 hours of

nursing

interventions the

patient will

participate in

prevention

measures and

treatment

program.

Long Term:

-after 2 days of

nursing

interventions the

patient will

demonstrate

increase self-

esteem AEB

changing stoma

pouch

independently

and promote

timely wound

healing.

Establish

rapport

Monitor and

record vital

signs

Assess

general

condition

Assess skin,

noted color,

turgor

sensation;

described and

measured

stoma and

observed

changes

Instruct family

to maintain

clean and dry

clothes

To gain

client’s trust

and

cooperation

To obtain

baseline data

To determine

interventions

needed by the

client

Establish

comparative

baseline

providing

opportunity

for timely

intervention

Skin friction

caused by stiff

or rough

clothes leads

Short Term:

-after 2 hours of

nursing

interventions the

patient shall

participate in

prevention

measures and

treatment

program.

Long Term:

-after 2 days of

nursing

interventions the

patient shall

demonstrate

increased self-

esteem AEB

changing stoma

pouch

independently

and promote

timely wound

healing.

Page 8: 8NCP's for colostomy

of a catheter, the

skin and tissues

then are closed

around the new

opening called

stoma.

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

Instruct the pt

that the pouch

should be

change every

4-5 days or

when leakage

occurs

Teach the pt

to empty the

pouch when it

is about half

to irritation

and increases

risk for

infection

To provide

proper ostomy

care and

prevent

complications

To increase

pt’s

knowledge on

proper ostomy

care

The client

should

demonstrate

Page 9: 8NCP's for colostomy

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

in stoma

assessment

and provided

mechanism

for

documenting

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

Necessary to

gather more

data

concerning

the pt

condition thus,

identifying

Page 10: 8NCP's for colostomy

Discuss pain

control if

needed

skin problem

and promoting

self-esteem

To help pt

coop towards

proper pain

management,

thus

minimizing

suffering

RISK FOR INJURY R/T PRESENCE OF STOMA 20HYPOKALEMIA

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

Page 11: 8NCP's for colostomy

S: ǿ

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 20

HYPOKALEMIA

Because

potassium is

needed for

normal nerve

conduction and

muscle function,

low plasma

potassium level

often lead to falls

and seizures due

to the procedures

prior and after

colostomy, the pt

is required to

empty the bowel

and be placed on

low residue diet

for several days

before the

surgery then

nothing by mouth

so as a result low

potassium level is

caused by

decrease food

intake.

Short Term:

-after 4 hours of

nursing

interventions the

patient will

demonstrate

behaviours to

reduce risk

factors and

protect self from

injury.

Long Term:

-after 1 week of

nursing

interventions the

patient will be

free from injury

and potassium

level will reach

the normal range.

Establish

rapport

Monitor and

record vital

signs

Assess

general

condition

Determining

precipitating

factors

Ascertain

knowledge of

safety needs/

injury

prevention

To gain

client’s trust

and

cooperation

To obtain

baseline data

To determine

interventions

needed by the

client

Identification

and

management

of underlying

cause is

essential to

recovery

To prevent

injury from

home

Short Term:

-after 4 hours of

nursing

interventions the

patient shall

demonstrate

behaviours to

reduce risk

factors and

protect self from

injury

Long Term:

-after 1 week of

nursing

interventions the

patient shall be

free from injury

and potassium

level shall reach

the normal range

Page 12: 8NCP's for colostomy

and

motivation

Put the bed on

lowest

position

Develop plan

of care within

the family to

meet pt’s

needs

Make sure

before the pt

walks, clear

the path of

obstacles and

place non-

slippery

shoes/slipper

Discuss the

importance of

adequate

nutrition

especially

To prevent

risk for falls

To meet the

needs without

injuries

To prevent

injury and falls

These provide

the pt

information on

how nutrition

could elevate

her chances of

Page 13: 8NCP's for colostomy

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

can’t be given

as IV push

INTERDEPENDEN

T:

Notify the

physician if

signs of

hypokalemia

persist or

worsen or

faster

recovery

To increase

plasma

potassium

level of the

body

To allow more

accurate

interventions

to the pt

Page 14: 8NCP's for colostomy

during the

administration

of IV

potassium

consult the

physician if

the client’s

urine is less

than 0.5

ml/kg/hr for 2

consecutive

hours if signs

of impaired

pheripheral

tissue

perfusion is

present

RISK FOR INFECTION R/T DISRUPTED SKIN INTEGRITY AFTER SURGERY AND PRESENCE OF STOMA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

Page 15: 8NCP's for colostomy

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ

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

Presence of

transverse

cut due to

CS

Incease

WBC count

(11.6×109

/L)

RISK FOR

INFECTION R/T

DISRUPTED SKIN

INTEGRITY AFTER

SURGERY AND

PRESENCE OF

STOMA

The skin is the

first line defence

of the body. Any

disruption in the

skin integrity may

act on a portal of

entry by

opportunistic

microorganisms

from the

environment. As

the healing

occurs,

microorganisms

can inhibit the

soiled stained

with blood. This

may cause

interruption to

the healing

process and can

cause infection

on the operation

site failure to

observe good

personal hygiene

Short Term:

-after 3 hours of

nursing

interventions the

patient will

demonstrate

techniques/

lifestyle changes

to promote safe

environment.

Long Term:

-after 2 days of

nursing

interventions the

patient will learn

how to do

interventions on

how to prevent or

reduce the risk of

infection and

promote timely

wound healing.

Establish

rapport

Monitor and

record vital

signs

Assess

general

condition

Note risk

factors of

having

infection in

the incision

site and stoma

Make health

teachings in

identification

of

environmental

To gain client’s

trust and

cooperation

To obtain

baseline data

To determine

interventions

needed by the

client

To help the

client identify

the present risk

factors that lead

to infection

To help the pt

modify or avoid

environmental

factors that

could prevent

infection

Short Term:

-after 3 hours of

nursing

interventions the

patient shall

demonstrate

techniques/

lifestyle changes

to promote safe

environment.

Long Term:

-after 2 days of

nursing

interventions the

patient shall

learn how to do

interventions on

how to prevent or

reduce the risk of

infection and

promote timely

wound healing.

Page 16: 8NCP's for colostomy

The pt may

manifest:

Fever

Pain,

itchiness

and

swelling

over the

peristomal

skin/incisio

n area

Redness

over the

incision site

can predispose a

person to

infection.

risk factors

that could

lead to

infection

Stress proper

hand hygiene

among all

caregivers, SO

and to the pt

Monitor pt’s

visitors

Recommend

routine or

preoperative

body showers

Instruct family

to maintain

clean and dry

clothes

preferably

cotton fabric

A first line

defence against

infection

To limit

exposure thus

reduce

contamination

To reduce

bacterial

colonizaon

Skin friction

caused by stiff

or rough clothes

leads to

irritation and

increases risk

for infection

Page 17: 8NCP's for colostomy

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

occurs

Teach the pt

to empty the

pouch when it

is about half

full and teach

on how to

To provide

proper ostomy

care and

prevent

complications

To increase pt’s

knowledge on

proper ostomy

care

The client

should

demonstrate the

ability to empty

and change the

pouch

Page 18: 8NCP's for colostomy

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

independently

before being

discharge

These provide

the pt

information on

how nutrition

could elevate

her chances of

faster recovery

DISTURBED BODY IMAGE R/T BIOPHYSICAL 20 COLOSTOMY

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

Page 19: 8NCP's for colostomy

S: ǿ

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 20

COLOSTOMY

The client with

ostomy faces

alterations in

self-concept and

body image.

This body image

is the attitude a

person has

about the actual

/perceived

structure or

function of all or

part of the body.

This attitude is

dynamic and is

altered through

interaction with

other people

and situations

as an important

part of one’s

self concept.

Body image

disturbance can

have profound

impact on how

individual view

Short Term:

-after 5 hours of

nursing

interventions

the patient will

be able to

verbalize

understanding

of body image

changes.

Long Term:

-after 2 days of

nursing

interventions

the patient will

demonstrate

and enhance

body image and

self-esteem AEB

ability to look at/

talk about and

care for actual

altered body

part/function.

Establish rapport

Monitor and record

vital signs

Assess general

condition

Assess perception

of change in

structure or

function of body

part

To gain

client’s trust

and

cooperation

To obtain

baseline data

To determine

interventions

needed by

the client

The extent of

response is

more related

to the value

of

importance

the pt places

on the

part/function

than actual

value

To

Short Term:

-after 5 hours of

nursing

interventions

the patient shall

be able to

verbalize

understanding

of body image

changes.

Long Term:

-after 2 days of

nursing

interventions

the patient shall

demonstrate

and enhance

body image and

self-esteem AEB

ability to look at/

talk about and

care for actual

altered body

part/function.

Page 20: 8NCP's for colostomy

their overall

self.

Assess perceived

impact of change

on activities of

daily living social

behaviour and

personal

responsibilities

Evaluate level of

pt’s knowledge of

and anxiety r/t

situation; observe

emotional changes

Note signs of

grieving/ indicators

of severe

depression

Determine ethnic

background and

cultural perceptions

and considerations

determined

how the pt

act to

changes

It may

indicate

acceptance

or non-

acceptance

of situation

To evaluate

need for

counselling

and/or

medications

May

influence

how

individual

deals with

what

happened

Page 21: 8NCP's for colostomy

Observe interaction

of client with SO’s

Establish

therapeutic nurse-

client relationship

conveying an

attitude of caring

and developing

trust acknowledge

the individual as

someone

worthwhile

Distortions in

body image

may be

unconsciousl

y reinforced

by family

members

and/ or

secondary

gain issues

may

interfere with

the progress

Provides

opportunities

for listening

to concerns

and

questions

To enhance

Page 22: 8NCP's for colostomy

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

Provide information

at clients level of

acceptance and is

small pieces, clarify

misconception

Begin counselling/

other

therapies(biofeedb

handling of

potential

situations

To begin

incorporate

changes into

body image

To minimize

body

changes and

enhance

appearance

To allow

easier

assimilations

To provide

early/

ongoing

sources of

support

Page 23: 8NCP's for colostomy

ack/ relaxation

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