ASSESSMENT DATA (Appropriate data to support nursing diagnosis, include subjective and objective data)
NURSING DIAGNOSIS (Must include scientific rationale for the diagnosis, include references*)
PLANNING Goals (include realistic short and long term client-centered goals)
Short Term/Long Term Interventions Short term: •During my shift, the ostomy and surrounding skin will intact without signs of breakdown.
50 year old male admitted to hospital with Sigmoid colon cancer
Risk for Impaired Skin Integrity R/T: Bowel Diversion ostomy
Client stated “I haven’t been that hungry the last few months”
“fecal material from a colostomy is irritating to the peristomal skin, any irritation or skin breakdown needs to be treated immediately” (Kozier and Erb, 2008 p.1345)
Abnormal Lab:
HGB
11.5 L
HCT
33.6 L
RBC
3.49 L
Lymphoc yte
17.7 L
Calcium
8.1
L
Protien
5
L
Albumin
2.5 L
Current body weight 156 Ideal body weight 172 lbs= 5’11’, 16 lbs under IBW Newly placed transverse Colostomy device Pain scale at 4
Long term: •In two weeks the ostomy site and surrounding skin will be intact and without signs of breakdown. •After teaching session the client and wife will be able to perform colostomy care with correct technique. Intervention: •keep skin clean by washing off and excretions (use warm water) and drying thoroughly (pat dry) •Stoma care: wearing clean gloves while changing a nondrainable pouch, •washing/drying skin thoroughly, •empting pouch at 1/2-1/3 full, while empting pouch place a tissue or gauze over stoma to absorb secretion, •assess Skin the of the stoma for active bleeding, ulceration, darker-colors with bluish hue, note burning sensation
NURSING IMPLEMENTATION (What actually was done, must include scientific rationale with references and delegation of tasks*)
1. Assisted/taught patient while draining colostomy bag before ½ full- nursing task/ not delegated
EVALUATION (Actual outcome of care and appropriate follow-up actions) Goals Implementations
1. Patient correctly drained colostomy device when partially full- follow up with patient throughout shift to offer assistance
Rationale: “weight of an overly full bag may loosen the skin barrier and separate it from the skin causing the stool to leak and irritate the peristomal skin” (Kozier and Erb, 2008 p.1347)- Initially performed by RN to properly teach client, then can be delegated to LPN or CNA 2. client cleansed stoma and peristomal skin with warm water, and pat dry. Initial nursing task/ CNA delegated Rationale: “stool can irritate peristomal skin” (Kozier and Erb, 2008 p.1347) “excess rubbing can abrade the skin” (Kozier and Erb, 2008 p.1348)- Initially performed by RN to properly teach client, then can be delegated to LPN or CNA 3. Assessed speristomal site for irritation, redness, ulceration, bleeding, and color while simultaneously teaching client
2. client properly cleanse peristomal skin and stoma while changing ostomy devicefurther education needed to help patient prepare for discharge
3. Peristomal skin and stoma was free from signs of irritation and breakdown. Patient and wife correctly identified
and wife the importance of good skin integrity and how to maintain it (e.g. cleansing ostomy and surrounding skin when changing colostomy bag, keeping site free of stool, detecting signs of tissue breakdown) -Not delegated
important signs of breakdown and irritation (redness, inflammation, burning, bleeding, change in color)
Rationale: “It is important to assess the peristomal skin for irritation” (Kozier and Erb, 2008 p.1345)
Imbalance Nutrition: Less than body requirements R/T: Inadequate absorption of nutrients AEB: Indication of low protein and albumin levels from CBC
“Because there is so much albumin in the body and because it is not broken down very quickly, albumin levels change slowly. Thus, a low level serum albumin level is a useful indicator of prolonged protein depletion.” (Kozier and Erb, 2008 p.1259)
Short term: •client will be able to select appropriate meal options to achieve needed protein intake by the end of client teaching
Long term: •client will gain 2 pounds in one week •clients total protein and albumin levels increase in two weeks Interventions: •asses clients food preference •consult with dietician •perform a nutritional assessment •avoid unpleasant or uncomfortable treatments immediately before or after meals •provide familiar foods in accordance with full liquid diet •full diet client teaching
1. client selected foods liked from full liquid diet to eat the following day- Delegated, nursing follow up
1. client selected liked foods form full diet list
Rationale: “Provide familiar food that the person likes. Often the relatives o clients are pleased to bring for from home but need some guidance about special diet requirements” (Kozier and Erb, 2008 p.1263) 2. assisted client with proper food selections for full liquid diet that are rich in protein Nursing task/ Dietician task Rationale: “client teaching: health nutrition, discuss foods high in specific nutrients required such as protein, iron, calcium, vitamin C, and fiber” (Kozier and Erb, 2008 p.1261) 3. provided client teaching on
2. client properly selected foods higher in protein to eat – follow up with client to plan for appropriate foods to eat after discharge on regular diet
\
3.client was taught to keep a food frequency record to track
•Advance to soft diet as tolerated •client food frequency record •client teaching protein and nutrient rich foods •monitor CBC (protein and albumin) •weekly weighing of client
food frequency record to help log protein intake- Nursing task
consumption of protein and nutrient rich foods
Rationale: “when specific foods or nutrients are suspected of being deficient or excessive, the health care professional may use a selective food frequency.” (Kozier and Erb, 2008 p.1257) 4. calculated clients ideal body weight- Delegated, Nursing follow up 5’11”= 172 lbs
4. client is underweight- client teaching needed for guidance in gaining healthy weight
Rationale: “Ideal body weight is the optimal weight recommended for optimal health” (Kozier and Erb, 2008 p.1236) 5. weighed client to determine gain/loss
5.clients weight was 156 no gain/loss- daily assessment needed
“dietary guidelines for Americans; maintain weight in a healthy range”
(Kozier and Erb, 2008 p.1246) Pain Related to Post operation placement of transverse ostomy AEB paitent stating “after moving around I am really hurting”
Short Term: •Patient will self identify pain level at or below comfort level during my shift
Long Term:
1.taught client 0-10 pain scaledelegated “to avoid confusion scales should us a 0-10 range with 0 indication no pain and highest number indicating worst pain
1. client voice understanding of pain scale- discontinue teaching
“pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage ”
•Until discharge patient will maintain comfort level with the use of non pharmacological pain relief Intervention: •Using Non Pharmacological pain relief •Teach pain scale •Distraction •Hot/Cold therapy •Assess Pain •Reduce stress •Emotional support
possible” (Kozier and Erb 2008, p.1198) 2.Assessed clients pain using 0-10 scale, nursing task “perception is reality, client’s self-report of pain is what must be used to determine pain intensity” (Kozier and Erb 2008, p.1198) 3.Provided emotional supportnursing task
2. client’s pain scale was at a 4 after ambulating in hallwayrefused analgesic, further assessment needed
3. talk with patient about problems he was having at home with his childrencontinue with implementation
“Therapeutic communication with an emphasis on listening providing encouragement teaching etc. promote coping” (Kozier and Erb 2008, p.1221) 4.Wife provided client with newspaper and crossword puzzle to work-can be done my family or nurse
**Low self-esteem related
to Ostomy **Disturbed Body Image related to Ostomy **Anxiety related to lack of control of fecal elimination secondary to ostomy
“Distraction allows the person’s attention away from the pain and lessens the perception of pain” (Kozier and Erb, 2008 p.1220)
4. client performed crossword for an hour, during this time I assessed his pain level pain level, client stated it was at a 2contiue with non pharmacological pain relief
