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

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ Nutritional Short Term:  Establish  To gain client’s Short Term:

O: The pt deficiencies -after 3 hours of rapport trust and -after 3 hours of
manifested: IMBALANCED primarily affects nursing cooperation nursing
 Low plasma NUTRITION; LESS gastrointestinal interventions the interventions the
level (2.73 THAN BODY disorder or due to patient will  Monitor and  To obtain patient shall
meqs/L) REQUIREMENT R/T the procedures verbalize record vital baseline data verbalize
 BMI (16.56) INSUFFICIENT prior and after understanding of signs understanding of
 Presence of INTAKE OF FOOD surgeries, in the causative factors causative factors
stoma in the RICH IN case of the pt, she and necessary  Assess general  To determine and necessary
right lower POTASSIUM AND is required to interventions to condition interventions interventions to
quadrant of INTESTINAL empty the bowel promote optimum needed by the promote optimum
the DISTURBANCES and be placed on nutrition. client nutrition.
abdomen low residue diet
for several days Long Term:  Determining  Identification Long Term:
The pt may before the surgery -after 8 hours of precipitating and -after 8 hours of
manifest: then nothing by nursing factors management nursing
 Muscle mouth so as a interventions the of underlying interventions the
weakness result nutritional patient will cause is patient shall
 Fatigue status of the pt is demonstrate essential to demonstrate
 Fall, injury, much likely behaviour recovery behaviour
seizures affected including changes to regain changes to regain
her plasma weight from BMI of  Assess ability to  These may limit weight from BMI of
potassium level. 16.56 to 18. chew, taste client’s ability 16.56 to 18.
and swallow to ingest food
and reducing
desire to eat
 Auscultate  Hypermotility
bowel sounds 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
 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 colostomy

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ A colostomy is a Short Term:  Establish  To gain client’s Short Term:

O: The pt surgical -after 2 hours of rapport trust and -after 2 hours of
manifested: IMPAIRED SKIN procedure that nursing cooperation nursing
 Presence of INTEGRITY R/T brings a portion of interventions the interventions the
stoma in the MECHANICAL the large intestine patient will  Monitor and  To obtain patient shall
right lower FACTORS through the participate in record vital baseline data participate in
quadrant of colostomy abdominal wall to prevention signs prevention
the carry out feces measures and measures and
 To determine
abdomen out of the body. In treatment  Assess general treatment
interventions
the case of the pt program. condition program.
needed by the
The pt may temporary
client
manifest: colostomy are Long Term: Long Term:
 Pain, created to divert -after 2 days of -after 2 days of
 Establish
itchiness stool from injured nursing  Assess skin, nursing
comparative
swelling of or diseased interventions the noted color, interventions the
baseline
the skin portion of the patient will turgor patient shall
providing
around the large intestine, demonstrate sensation; demonstrate
opportunity for
stoma allowing rest and increase self- described and increased self-
timely
 infection healing. It is done esteem AEB measured esteem AEB
intervention
by accurate changing stoma stoma and changing stoma
depiction of pouch observed pouch
colorectal surgery independently changes independently
beginning with a and promote  Instruct family  Skin friction and promote
midline incision, timely wound to maintain caused by stiff timely wound
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 for infection
around the new
opening called  Instruct the pt  To provide
stoma. 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
 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 self-
esteem

 Discuss pain  To help pt

control if coop towards
needed proper pain
management,
thus minimizing
suffering
RISK FOR INJURY R/T PRESENCE OF STOMA HYPOKALEMIA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ Because Short Term:  Establish  To gain client’s Short Term:

O: The pt potassium is -after 4 hours of rapport trust and -after 4 hours of
manifested: RISK FOR INJURY needed for nursing cooperation nursing
 Presence of R/T PRESENCE OF normal nerve interventions the interventions the
stoma in the STOMA conduction and patient will  Monitor and  To obtain patient shall
right lower HYPOKALEMIA muscle function, demonstrate record vital baseline data demonstrate
quadrant of low plasma behaviours to signs behaviours to
the potassium level reduce risk factors reduce risk factors
 To determine
abdomen often lead to falls and protect self  Assess general and protect self
interventions
 Low and seizures due from injury. condition from injury
needed by the
potassium to the procedures
client
level (2.73 prior and after Long Term: Long Term:
meqs/L) colostomy, the pt -after 1 week of -after 1 week of
 Identification
is required to nursing  Determining nursing
and
The pt may empty the bowel interventions the precipitating interventions the
management
manifest: and be placed on patient will be free factors patient shall be
of underlying
 Muscle low residue diet from injury and free from injury
cause is
weakness for several days potassium level and potassium
essential to
 Falls and before the surgery will reach the level shall reach
recovery
seizures then nothing by normal range. the normal range
mouth so as a
 To prevent
result low  Ascertain
potassium level is knowledge of injury from
caused by safety needs/ home
decrease food injury
intake. prevention
and motivation

 Put the bed on

 To prevent risk
lowest position
for falls

 Develop plan  To meet the

of care within needs without

the family to injuries

meet pt’s
needs

 Make sure
 To prevent
before the pt
injury and falls
walks, clear
the path of
obstacles and
place non-
slippery
shoes/slipper

 These provide
 Discuss the
 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
 To increase
give oral/iv
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 NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ The skin is the first Short Term:  Establish  To gain client’s Short Term:
O: The pt line defence of -after 3 hours of rapport trust and -after 3 hours of
manifested: RISK FOR the body. Any nursing cooperation nursing
 Presence of INFECTION R/T disruption in the interventions the interventions the
stoma in the DISRUPTED SKIN skin integrity may patient will  Monitor and  To obtain patient shall
right lower INTEGRITY AFTER act on a portal of demonstrate record vital baseline data demonstrate
quadrant of SURGERY AND entry by techniques/ signs techniques/
the PRESENCE OF opportunistic lifestyle changes lifestyle changes
 To determine
abdomen STOMA microorganisms to promote safe  Assess general to promote safe
interventions
 Dry and from the environment. condition environment.
needed by the
intact environment. As
client
midline the healing Long Term: Long Term:
incision of occurs, -after 2 days of -after 2 days of
the microorganisms nursing  Note risk nursing
 To help the client
abdomen can inhibit the interventions the factors of interventions the
identify the
for about 5- soiled stained with patient will learn having patient shall learn
present risk
6 inches blood. This may how to do infection in the how to do
factors that lead
 Presence of cause interruption interventions on incision site interventions on
to infection
transverse to the healing how to prevent or and stoma how to prevent or
cut due to process and can reduce the risk of reduce the risk of
 To help the pt
CS cause infection on infection and  Make health infection and
modify or avoid
 Incease the operation site promote timely teachings in promote timely
 WBC count failure to observe wound healing. identification environmental wound healing.
(11.6× /L) good personal of factors that
hygiene can environmental could prevent
The pt may predispose a risk factors that infection
manifest: person to could lead to
 Fever infection. infection
 Pain,
itchiness
 Stress proper
and swelling  A first line
hand hygiene
over the defence against
among all
peristomal infection
caregivers, SO
skin/incision
and to the pt
area
 Redness
 Monitor pt’s
over the  To limit exposure
visitors
incision site thus reduce
contamination

 Recommend
 To reduce
routine or
bacterial
preoperative
colonizaon
body showers

 Instruct family
 Skin friction
to maintain
caused by stiff or
 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
 To increase pt’s
that the pouch
knowledge on
should be
proper ostomy
change every
care
4-5 days or
when leakage
occurs
 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
 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
DISTURBED BODY IMAGE R/T BIOPHYSICAL COLOSTOMY

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME

S: ǿ The client with Short Term:  Establish rapport  To gain Short Term:
O: The pt ostomy faces -after 5 hours of client’s trust -after 5 hours of
manifested: DISTURBED BODY alterations in self- nursing and nursing
 Presence of IMAGE R/T concept and interventions the cooperation interventions the
stoma in the BIOPHYSICAL body image. This patient will be patient shall be
right lower COLOSTOMY body image is able to verbalize  Monitor and record  To obtain able to verbalize
quadrant of the attitude a understanding of vital signs baseline data understanding of
the abdomen person has body image body image
 Dry and about the actual changes. changes.
 To determine
intact midline /perceived  Assess general
interventions
incision of the structure or Long Term: condition Long Term:
needed by
abdomen for function of all or -after 2 days of -after 2 days of
the client
about 5-6 part of the body. nursing nursing
inches This attitude is interventions the interventions the
 The extent of
 Naming dynamic and is patient will  Assess perception of patient shall
response is
changed altered through demonstrate and change in structure demonstrate and
more related
body part or interaction with enhance body or function of body enhance body
to the value
function other people image and self- part image and self-
of
 BMI of 16.56 and situations as esteem AEB esteem AEB
importance
(underweight) an important ability to look at/ ability to look at/
the pt places
part of one’s self talk about and talk about and
on the
concept. Body care for actual 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  Assess perceived
 To
their overall self. impact of change
determined
on activities of daily
how the pt
living social
act to
behaviour and
changes
personal
responsibilities

 Evaluate level of
 It may
pt’s knowledge of
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  Distortions in

of client with SO’s 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
 These provide
importance of
the pt
adequate nutrition
information
especially fluids,
on how
protein, vit.C, vit.B,
nutrition
iron calories and
could elevate
potassium rich foods
her chances
of faster
recovery