IMBALANCED NUTRITION; LESS THAN BODY REQUIREMENT R/T INSUFFICIENT INTAKE OF FOOD RICH IN POTASSIUM AND INTESTINAL DISTURBANCES
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
DIAGNOSIS
EXPLANATION
NURSING
Nutritional
Short Term:
O: The pt
deficiencies
-after 3 hours of
primarily
nursing
Low plasma level (2.73 meqs/L)
IMBALANCED NUTRITION; LESS
affects
gastrointestinal
interventions
the
disorder or due to
patient
will
REQUIREMENT R/T
the
procedures
verbalize
prior
and
THAN BODY
BMI (16.56)
INSUFFICIENT
Presence of
INTAKE OF FOOD
stoma in the
RICH IN
surgeries,
after understanding in
the
Short Term:
trust and
-after 3 hours of
cooperation
nursing interventions
Monitor and
record vital of
To obtain
patient
baseline data
verbalize
signs
necessary
shall
understanding
of
causative factors
and
necessary
interventions
interventions
promote optimum
needed by the
promote optimum
DISTURBANCES
and be placed on
nutrition.
client
nutrition.
Identification
Long Term:
precipitating
and
-after 8 hours of
factors
management
nursing
the
of underlying
interventions
will
cause is
patient
essential to
demonstrate
recovery
behaviour
several
condition
To determine
empty the bowel
residue
to
Assess general
INTESTINAL
low
interventions
the
quadrant of
for
to
diet days
Long Term:
The pt may
before the surgery
manifest:
then nothing by nursing as
-after 8 hours of
Muscle
mouth
so
weakness
result
nutritional
Fatigue
status of the pt is
Fall, injury,
much
seizures
affected including
changes to regain
her
weight from BMI of
rapport
To gain client’s
POTASSIUM AND
abdomen
to
right lower
the
required
Establish
OUTCOME
causative factors
case of the pt, she and is
EXPECTED
INTERVENTIONS
S: ǿ
manifested:
RATIONALE
a interventions patient
Determining
demonstrate
likely behaviour
plasma
the shall
changes to regain
Assess ability to
These may limit
weight from BMI of
potassium level.
16.56 to 18.
chew, taste
client’s ability
and swallow
to ingest food and reducing desire to eat
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
Indicator of
indicated,
nutritional
evaluate
needs and
weight in terms
adequacy of
of premorbid
intake
weight compare serial weights and anthropometri c measures
16.56 to 18.
Plan diet with
Including the
client and SO,
pt in planning
incorporating
gives a sense
foods that
of control of
client’s want or
environment
food from
and may
home
enhance intake
Encouraged
Fulfilling
small frequent
cravings for
meals and
desired food
snacks of
may also
nutritionally
improve intake
dense and non-acidic foods
Discussed the
These provide
importance of
the pt
adequate
information on
nutrition
how nutrition
especially
could elevate
fluids, protein,
her chances of
vit.C, vit.B, iron
faster recovery
calories and potassium rich foods
Instructed the
To diminish
pt to limit foods
gastric irritants
that include
that may
nausea and
cause client to
vomiting,
be reluctant to
avoid serving
eat
very hot and spicy foods
Schedule
Gastric fullness
medications
diminishes
between
appetite and
meals if
food intake
tolerated and limit fluid intake with meals unless fluid has nutritional value
Keep strict
It is necessary
documentatio
to make an
n of intake
accurate
output and
nutritional
calorie count
assessment
Dependent:
Administer
Reduces
medications as
incidence of
indicated and
nausea and
ordered for
vomiting
example
possibly
antiemetics
enhancing oral intake
Administer
To increase
vitamin and
nutritional
mineral
intake
supplements as ordered by the physician
Interdependent:
In
To provide
collaboration
adequate
with the
nutrition and
dietician,
realistic weight
determine
gain
number of calories required to provide adequate nutrition and realistic weight gain
IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS
ASSESSMENT
colostomy
NURSING
SCIENTIFIC
OBJECTIVES
DIAGNOSIS
EXPLANATION
NURSING INTERVENTIONS
S: ǿ
A colostomy is a
Short Term:
O: The pt
surgical
-after 2 hours of
manifested:
procedure
Presence of
INTEGRITY R/T
brings a portion of
interventions
the
stoma in the
MECHANICAL
the large intestine
patient
will
quadrant of the abdomen
FACTORS
colostomy
through
that
abdominal wall to
prevention
carry
measures
out
feces
out of the body. In
The pt may
temporary
manifest:
colostomy
Pain, itchiness swelling of the skin around the stoma
infection
are
stool from injured diseased
portion
of
large
the
intestine,
allowing rest and
accurate
depiction
rapport
To gain client’s
Short Term:
trust and
-after 2 hours of
cooperation
nursing interventions
in
Monitor and
record vital
To obtain
patient
baseline data
participate
signs
treatment
shall in
measures
program.
Assess general
the
prevention
and
To determine interventions
condition
client
Long Term:
-after 2 days of nursing
and
treatment program.
interventions patient
of
colorectal surgery
the will
demonstrate increase
changing
Assess skin, noted color, turgor sensation;
selfAEB stoma
Long Term:
-after 2 days of
healing. It is done esteem by
needed by the
created to divert
or
Establish
EXPECTED OUTCOME
nursing
the participate
the case of the pt
IMPAIRED SKIN
right lower
RATIONALE
described and measured stoma and
Establish comparative baseline providing opportunity for timely intervention
nursing interventions patient
the shall
demonstrate increased
self-
esteem
AEB
changing
stoma
pouch
observed
pouch
independently
changes
independently
beginning with a and
Skin friction
and
to maintain
caused by stiff
timely
then colon is cut healing.
clean and dry
or rough
healing.
to allow insertion
clothes
clothes leads
of a catheter, the
preferably
to irritation and
skin
and
tissues
cotton fabric
increases risk
then
are
closed
midline
incision,
timely
promote
wound
Instruct family
for infection
around the new opening
called
stoma.
Instruct the pt
To provide
that the
proper ostomy
peristomal
care and
area should be
prevent
cleaned well
complications
with a mild soap and dried before the new pouch is applied
Instruct the pt
To increase
that the pouch
pt’s
should be
knowledge on
change every
proper ostomy
4-5 days or
care
when leakage
promote wound
occurs
Teach the pt to
The client
empty the
should
pouch when it
demonstrate
is about half
the ability to
full and teach
empty and
on how to
change the
clean out the
pouch
pouch
independently
properly when
before being
emptying it
discharge
Discuss the
These provide
importance of
the pt
adequate
information on
nutrition
how nutrition
especially
could elevate
fluids, protein,
her chances of
vit.C, vit.B, iron
faster recovery
calories and potassium rich foods
Instruct the pt
Necessary to
in stoma
gather more
assessment
data
and provided
concerning
mechanism for
the pt
documenting
condition thus, identifying skin problem and promoting selfesteem
Discuss pain
To help pt
control if
coop towards
needed
proper pain management, thus minimizing suffering
RISK FOR INJURY R/T PRESENCE OF STOMA
ASSESSMENT
HYPOKALEMIA
NURSING
SCIENTIFIC
DIAGNOSIS
EXPLANATION
S: ǿ
Because
O: The pt
potassium
manifested:
RISK FOR INJURY
needed
Presence of
R/T PRESENCE OF
normal
stoma in the
STOMA
right lower
HYPOKALEMIA
potassium
-after 4 hours of
interventions
and patient
will
plasma level
often lead to falls and seizures due
behaviours
and protect self
Falls and seizures
to
empty the bowel and be placed on
for
residue several
diet days
before the surgery then nothing by mouth result
so
Monitor and
as
trust and
-after 4 hours of
cooperation
nursing
To obtain
patient
baseline data
demonstrate
signs
shall
to
reduce risk factors
Assess general
To determine interventions
and protect self from injury
needed by the client
nursing
interventions
the
injury
potassium will
Determining
management
factors
of underlying
and
cause is
level
reach
Identification and
precipitating
patient will be free from
Long Term:
-after 1 week of
essential to
the
recovery
normal range.
a low
the
behaviours
condition
colostomy, the pt -after 1 week of
weakness
after Long Term:
required
Short Term:
interventions
from injury.
meqs/L)
and
To gain client’s
reduce risk factors
prior
low
rapport
to
level (2.73
Muscle
record vital
to the procedures
manifest:
Establish
the
potassium
The pt may
function, demonstrate
the
is
is
conduction
EXPECTED OUTCOME
for nursing
low
Low
RATIONALE
INTERVENTIONS
nerve
muscle
NURSING
Short Term:
quadrant of
abdomen
OBJECTIVES
Ascertain
To prevent
nursing interventions
the
patient
be
free and
shall
from
injury
potassium
level shall reach the normal range
potassium level is
knowledge of
injury from
caused
safety needs/
home
decrease
by food
injury
intake.
prevention and motivation
Put the bed on lowest position
Develop plan
To prevent risk for falls
To meet the
of care within
needs without
the family to
injuries
meet pt’s needs
Make sure
before the pt
To prevent injury and falls
walks, clear the path of obstacles and place nonslippery shoes/slipper
Discuss the
These provide
importance of
the pt
adequate
information on
nutrition
how nutrition
especially
could elevate
fluids, protein,
her chances of
vit.C, vit.B, iron
faster recovery
calories and potassium rich foods
DEPENDENT:
Administer or give oral/iv
To increase plasma
potassium as
potassium level
prescribed
of the body
ensuring that it is diluted in IV
fluids it can’t be given as IV push
INTERDEPENDENT:
Notify the
To allow more
physician if
accurate
signs of
interventions to
hypokalemia
the pt
persist or worsen or 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
DIAGNOSIS
EXPLANATION
NURSING INTERVENTIONS
S: ǿ
The skin is the first
Short Term:
O: The pt
line
defence
-after 3 hours of
the
body.
manifested:
Presence of
INFECTION R/T
disruption
stoma in the
DISRUPTED SKIN
right lower
INTEGRITY AFTER
quadrant of the abdomen
Dry and
the
skin integrity may
patient
will
act on a portal of
demonstrate
record vital
SURGERY AND
entry
techniques/
signs
PRESENCE OF
opportunistic
by
lifestyle
microorganisms from
occurs,
-after 2 days of
the
microorganisms
nursing
Presence of
the
soiled stained with blood.
This
may
cause interruption the
trust and
-after 3 hours of
cooperation
nursing
To obtain
patient
baseline data
demonstrate
Assess general
shall
techniques/ lifestyle
the
To determine interventions
changes
to promote safe environment.
needed by the
incision of
6 inches
Monitor and
condition
the
inhibit
environment.
midline
can
Short Term:
interventions
As
healing
To gain client’s
changes
to promote safe
the
rapport
the
EXPECTED OUTCOME
nursing
environment.
for about 5-
Any
Establish
interventions
STOMA
in
of
intact
abdomen
RISK FOR
RATIONALE
client
Long Term:
-after 2 days of
interventions
the
to
interventions
healing
how to prevent or
cut due to
process and can
reduce the risk of
CS
cause infection on
infection
and
Incease
the operation site
promote
timely
To help the client identify the present risk
infection in the
on
to
nursing
having
do
transverse
Note risk factors of
patient will learn how
Long Term:
factors that lead
incision site
to infection
and stoma
interventions
the
patient shall learn how
to
interventions
do on
how to prevent or reduce the risk of
Make health teachings in
To help the pt modify or avoid
infection
and
promote
timely
WBC count
failure to observe
(11.6× /L)
good
wound healing.
identification
environmental
of
factors that
can
environmental
could prevent infection
personal
hygiene The pt may
predispose
a
risk factors that
manifest:
person
to
could lead to
Fever
Pain,
infection.
infection
itchiness and swelling
hand hygiene
over the
A first line defence against
among all
peristomal
infection
caregivers, SO
skin/incision
and to the pt
area
Stress proper
Redness over the
Monitor pt’s
visitors
incision site
To limit exposure thus reduce contamination
Recommend
routine or
To reduce bacterial
preoperative
colonizaon
body showers
Instruct family to maintain
Skin friction caused by stiff or
wound healing.
clean and dry
rough clothes
clothes
leads to irritation
preferably
and increases risk
cotton fabric
for infection
Instruct the pt
To provide
that the
proper ostomy
peristomal
care and
area should be
prevent
cleaned well
complications
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
To increase pt’s knowledge on proper ostomy care
Teach the pt
The client should
to empty the
demonstrate the
pouch when it
ability to empty
is about half
and change the
full and teach
pouch
on how to
independently
clean out the
before being
pouch
discharge
properly when emptying it
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
COLOSTOMY
NURSING
SCIENTIFIC
DIAGNOSIS
EXPLANATION
S: ǿ
The
O: The pt
ostomy
manifested:
Presence of stoma in the right lower
BIOPHYSICAL COLOSTOMY
faces
alterations in selfconcept
with Short Term: -after 5 hours of
client’s trust
-after 5 hours of
nursing
and
nursing
cooperation
interventions the
patient will be
body
image
is
able to verbalize
attitude
a
understanding of
person
Dry and
about the actual
has
intact midline
/perceived
incision of the
structure
Monitor and record
vital signs
This
interventions the
is
dynamic and is altered
through
interaction other
and situations as an
patient will demonstrate and
with enhance body
people
important
image and selfesteem AEB ability to look at/
part of one’s self talk about and concept.
able to verbalize
baseline data
understanding of
changes. Assess general
Body care for actual
To determine interventions
condition
needed by
function of all or -after 2 days of
attitude
To obtain
body image
or Long Term:
inches
(underweight)
nursing
BMI of 16.56
patient shall be
changes.
part of the body.
function
body image
about 5-6
body part or
OUTCOME Short Term:
Establish rapport
EXPECTED
To gain
body image. This
the abdomen
Naming
RATIONALE
and interventions the
the
changed
IMAGE R/T
NURSING INTERVENTIONS
quadrant of
abdomen for
DISTURBED BODY
client
OBJECTIVES
the client
Long Term: -after 2 days of nursing interventions the
Assess perception of change in structure or function of body part
The extent of response is more related to the value of importance the pt places on the
patient shall demonstrate and enhance body image and selfesteem AEB ability to look at/ talk about and care for actual
image
altered body
part/function
altered body
disturbance can
part/function.
than actual
part/function.
have
profound
value
impact on how individual
view
their overall self.
Assess perceived impact of change
To determined
on activities of daily
how the pt
living social
act to
behaviour and
changes
personal responsibilities
Evaluate level of
pt’s knowledge of
It may indicate
and anxiety r/t
acceptance
situation; observe
or non-
emotional changes
acceptance of situation
Note signs of
To evaluate
grieving/ indicators
need for
of severe depression
counselling and/or medications
Determine ethnic
May
background and
influence
cultural perceptions
how
and considerations
individual deals with what happened
Observe interaction
of client with SO’s
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
opportunities
relationship
for listening to
conveying an
concerns and
attitude of caring
questions
and developing trust acknowledge the individual as someone worthwhile
Encourage
To enhance
verbalizations of
handling of
and role play
potential
anticipated conflicts
situations
Encourage the
To begin
client to use denial
incorporate
without
changes into
participating
body image
Help the client to
To minimize
select and use
body
clothing/make up
changes and enhance appearance
Provide information
To allow
at clients level of
easier
acceptance and is
assimilations
small pieces, clarify misconception
Begin counselling/
To provide
other
early/
therapies(biofeedb
ongoing
ack/ relaxation
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
