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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
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.
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
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
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
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
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.
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
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
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
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
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
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
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
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.
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
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
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
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.
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
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
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
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