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: Nutritional Short Term: Establish To gain Short Term:
O: The pt deficiencies -after 3 hours of rapport clients trust -after 3 hours of
manifested: IMBALANCED primarily affects nursing and nursing
Low plasma NUTRITION; LESS gastrointestinal interventions the Monitor and cooperation interventions the
level (2.73 THAN BODY disorder or due to patient will record vital patient shall
To obtain
meqs/L) REQUIREMENT the procedures verbalize signs verbalize
baseline data
BMI (16.56) R/T INSUFFICIENT prior and after understanding of understanding of
Presence of Assess
INTAKE OF FOOD surgeries, in the causative factors causative factors
stoma in general
RICH IN case of the pt, and necessary and necessary
the right condition To determine
POTASSIUM AND she is required to interventions to interventions to
lower interventions
INTESTINAL empty the bowel promote optimum promote optimum
quadrant of needed by the
DISTURBANCES and be placed on nutrition. Determining nutrition.
the client
low residue diet precipitating
abdomen
for several days Long Term: Identification Long Term:
factors
before the -after 8 hours of and -after 8 hours of
The pt may
surgery then nursing management nursing
manifest:
nothing by mouth interventions the of underlying interventions the
Muscle
so as a result patient will cause is patient shall
weakness Assess ability
Fatigue nutritional status demonstrate essential to demonstrate
to chew, taste
Fall, injury,
of the pt is much behaviour recovery behaviour
and swallow
seizures
likely affected changes to regain changes to regain
including her weight from BMI These may weight from BMI
Auscultate
plasma of 16.56 to 18. limit clients of 16.56 to 18.
potassium level. bowel sounds ability to
ingest food
and reducing
desire to eat
Hypermotility
of intestinal
tract is
common and
is associated
with vomiting
and diarrhea
Weigh as
which may
indicated,
affect choice
evaluate
of diet/route
weight in
terms of Indicator of
premorbid nutritional
weight needs and
compare serial adequacy of
weights and intake
anthropometri
c measures
Plan diet with
client and SO,
incorporating
foods that
Including the
clients want
pt in planning
or food from
gives a sense
 home of control of
environment
Encouraged and may
small frequent enhance
meals and intake
snacks of
Fulfilling
nutritionally
cravings for
dense and
desired food
non-acidic
may also
foods
improve
Discussed the intake
importance of
adequate
nutrition These provide
especially
the pt
fluids, protein,
information on
vit.C, vit.B,
how nutrition
iron calories
could elevate
and potassium
her chances of
rich foods
faster
recovery
Instructed the
pt to limit
foods that
To diminish
include
gastric
nausea and
irritants that
 vomiting, may cause
avoid serving client to be
very hot and reluctant to
spicy foods eat

Schedule
medications
between
Gastric
meals if
fullness
tolerated and
diminishes
limit fluid
appetite and
intake with
food intake
meals unless
fluid has
nutritional
value

Keep strict
documentatio
n of intake
It is necessary
output and
to make an
calorie count
accurate
nutritional
Dependent:
assessment

Administer
medications
 as indicated Reduces
and ordered incidence of
for example nausea and
antiemetics vomiting
possibly
Administer enhancing
vitamin and oral intake
mineral
To increase
supplements
nutritional
as ordered by
intake
the physician

Interdependent
:

In
collaboration
To provide
with the
adequate
dietician,
nutrition and
determine
realistic
number of
weight gain
calories
required to
provide
adequate
nutrition and
realistic
weight gain
 0
IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS 2 colostomy

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: A colostomy is a Short Term: Establish To gain clients 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 interventions the Monitor and interventions the
To obtain
stoma in MECHANICAL of the large patient will record vital patient shall
baseline data
the right 0 intestine through participate in signs participate in
FACTORS 2
lower the abdominal prevention prevention
Assess To determine
quadrant of colostomy wall to carry out measures and measures and
general interventions
the feces out of the treatment treatment
condition needed by the
abdomen body. In the case program. program.
client
of the pt
The pt may Establish
temporary Long Term: Assess skin, Long Term:
manifest: comparative
colostomy are -after 2 days of noted color, -after 2 days of
Pain, baseline
created to divert nursing turgor nursing
itchiness stool from injured interventions the providing interventions the
sensation;
swelling of or diseased patient will opportunity patient shall
described and
the skin portion of the demonstrate for timely demonstrate
measured
around the large intestine, increase self- intervention increased self-
stoma and
stoma allowing rest and esteem AEB esteem AEB
infection observed
healing. It is done changing stoma changes changing stoma
by accurate pouch Instruct family Skin friction pouch
depiction of independently to maintain caused by stiff independently
colorectal surgery and promote clean and dry or rough and promote
beginning with a timely wound clothes clothes leads timely wound
midline incision, healing. preferably to irritation healing.
then colon is cut cotton fabric and increases
to allow insertion risk for
of a catheter, the Instruct the pt infection
skin and tissues that the
To provide
then are closed peristomal
proper ostomy
around the new area should be
care and
opening called cleaned well
prevent
stoma. with a mild
complications
soap and
dried before
the new pouch
is applied

Instruct the pt
that the pouch
To increase
should be
pts
change every
knowledge on
4-5 days or
proper ostomy
when leakage
care
occurs

Teach the pt
to empty the
pouch when it
The client
is about half
should
full and teach
demonstrate
 on how to the ability to
clean out the empty and
pouch change the
properly when pouch
emptying it independently
before being
Discuss the
discharge
importance of
adequate
These provide
nutrition
the pt
especially
information on
fluids, protein,
how nutrition
vit.C, vit.B,
could elevate
iron calories
her chances of
and potassium
faster
rich foods
recovery
Instruct the pt
in stoma
assessment
and provided
mechanism Necessary to
for
gather more
documenting
data
concerning
the pt
condition
Discuss pain
thus,
control if identifying
needed skin problem
and promoting
self-esteem

To help pt
coop towards
proper pain
management,
thus
minimizing
suffering
 0
RISK FOR INJURY R/T PRESENCE OF STOMA 2 HYPOKALEMIA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: Because Short Term: Establish To gain Short Term:
O: The pt potassium is -after 4 hours of rapport clients trust -after 4 hours of
manifested: RISK FOR INJURY needed for nursing and nursing
Presence of R/T PRESENCE OF normal nerve interventions the cooperation interventions the
stoma in conduction and patient will Monitor and patient shall
STOMA 20
the right muscle function, demonstrate record vital To obtain demonstrate
lower HYPOKALEMIA low plasma behaviours to signs baseline data behaviours to
quadrant of potassium level reduce risk reduce risk
Assess
the often lead to falls factors and factors and
general To determine
abdomen and seizures due protect self from protect self from
Low condition interventions
to the procedures injury. injury
potassium needed by the
prior and after
level (2.73 client
colostomy, the pt Long Term: Long Term:
meqs/L) is required to -after 1 week of Identification -after 1 week of
Determining
empty the bowel nursing precipitating and nursing
The pt may
and be placed on interventions the factors management interventions the
manifest:
low residue diet patient will be of underlying patient shall be
Muscle
for several days free from injury cause is free from injury
weakness
Falls and before the and potassium essential to and potassium

seizures surgery then level will reach recovery level shall reach
nothing by mouth the normal range. the normal range
so as a result low Ascertain To prevent
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 for falls
position
To meet the
needs without
Develop plan
injuries
of care within
the family to
meet pts
needs
To prevent
Make sure
injury and falls
before the pt
walks, clear
the path of
obstacles and
place non-
slippery
shoes/slipper
These provide
Discuss the the pt
importance of information on
adequate how nutrition
nutrition could elevate
 especially her chances of
fluids, protein, faster
vit.C, vit.B, recovery
iron calories
and potassium
rich foods

DEPENDENT:

Administer or
give oral/iv To increase

potassium as plasma

prescribed potassium

ensuring that level of the

it is diluted in body

IV fluids it
cant be given
as IV push

INTERDEPENDENT
:

Notify the
To allow more
physician if
accurate
signs of
interventions
hypokalemia
to the pt
persist or
 worsen or
during the
administration
of IV
potassium
consult the
physician if
the clients
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: The skin is the Short Term: Establish To gain clients Short Term:
O: The pt first line defence -after 3 hours of rapport trust and -after 3 hours of
manifested: RISK FOR of the body. Any nursing cooperation nursing
Presence of INFECTION R/T disruption in the interventions the Monitor and interventions the
To obtain
stoma in DISRUPTED SKIN skin integrity patient will record vital patient shall
baseline data
the right INTEGRITY AFTER may act on a demonstrate signs demonstrate
lower SURGERY AND portal of entry by techniques/ techniques/
Assess To determine
quadrant of PRESENCE OF opportunistic lifestyle changes lifestyle changes
general interventions
the STOMA microorganisms to promote safe to promote safe
condition needed by the
abdomen from the environment. environment.
Dry and client
environment. As
intact the healing Long Term: Long Term:
midline occurs, -after 2 days of -after 2 days of
Note risk To help the
incision of microorganisms nursing nursing
factors of client identify
the can inhibit the interventions the interventions the
having the present risk
abdomen soiled stained patient will learn patient shall learn
infection in factors that lead
for about with blood. This how to do how to do
the incision to infection
5-6 inches may cause interventions on interventions on
Presence of site and
To help the pt
interruption to how to prevent or stoma how to prevent or
transverse modify or avoid
the healing reduce the risk of reduce the risk of
cut due to Make health environmental
process and can infection and infection and
CS teachings in factors that
Incease cause infection promote timely promote timely
identification could prevent
WBC count on the operation wound healing. wound healing.
of infection
(11.6 site failure to
environmental
observe good
risk factors
 10
9 personal hygiene that could
/L)
can predispose a lead to
person to infection A first line
The pt may
infection. defence against
manifest:
Stress proper infection
Fever
Pain, hand hygiene
itchiness among all
and caregivers, SO
swelling and to the pt To limit
over the exposure thus
Monitor pts
peristomal reduce
visitors
skin/incisio contamination
n area
Recommend To reduce
Redness
routine or bacterial
over the
preoperative colonizaon
incision site
body showers

Instruct family
Skin friction
to maintain
caused by stiff
clean and dry
or rough clothes
clothes
leads to
preferably
irritation and
cotton fabric
increases risk
for infection
Instruct the pt
that the To provide
peristomal proper ostomy
 area should care and
be cleaned prevent
well with a complications
mild soap and
dried before
the new pouch
is applied

Instruct the pt
that the pouch
To increase pts
should be
knowledge on
change every
proper ostomy
4-5 days or
care
when leakage
occurs

Teach the pt
to empty the
pouch when it The client
is about half
should
full and teach
demonstrate the
on how to
ability to empty
clean out the
and change the
pouch
pouch
properly when
independently
emptying it
before being
discharge
 Discuss the
importance of
adequate
nutrition
especially These provide
fluids, protein, the pt
vit.C, vit.B, information on
iron calories how nutrition
and potassium could elevate
rich foods her chances of
faster recovery

0
DISTURBED BODY IMAGE R/T BIOPHYSICAL 2 COLOSTOMY

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: The client with Short Term: Establish rapport To gain Short Term:
O: The pt ostomy faces -after 5 hours of clients trust -after 5 hours of
manifested: DISTURBED alterations in nursing and nursing
Presence of BODY IMAGE self-concept and interventions cooperation interventions
Monitor and record
stoma in the R/T body image. the patient will the patient shall
vital signs To obtain
right lower BIOPHYSICAL This body image be able to be able to
baseline data
quadrant of is the attitude a verbalize verbalize
20 Assess general
the abdomen person has understanding understanding
Dry and condition
COLOSTOMY about the actual of body image To determine of body image
intact /perceived changes. interventions changes.
midline structure or needed by
incision of function of all or Long Term: the client Long Term:
Assess perception
the abdomen part of the body. -after 2 days of -after 2 days of
of change in The extent of
for about 5- This attitude is nursing nursing
structure or response is
6 inches dynamic and is interventions interventions
Naming function of body more related
altered through the patient will part to the value the patient shall
changed
interaction with demonstrate of demonstrate
body part or
other people and enhance importance and enhance
function
BMI of 16.56 and situations body image and the pt places body image and
(underweight as an important self-esteem AEB self-esteem AEB
on the
) part of ones ability to look at/ ability to look at/
part/function
self concept. talk about and than actual talk about and
Body image care for actual value care for actual
disturbance can altered body altered body
have profound part/function. Assess perceived To part/function.
impact on how impact of change determined
individual view on activities of how the pt
their overall daily living social act to
self. behaviour and changes
personal
responsibilities

Evaluate level of
It may
pts knowledge of
indicate
and anxiety r/t
acceptance
situation; observe
or non-
emotional changes
acceptance
of situation
Note signs of
grieving/ indicators To evaluate
of severe need for
depression counselling
and/or
Determine ethnic medications
May
background and
influence
cultural
how
perceptions and
individual
considerations
deals with
what
happened

Distortions in
Observe interaction
body image
of client with SOs
 may be
unconsciousl
y reinforced
by family
members
and/ or
secondary
gain issues
may
interfere with
the progress

Establish Provides
therapeutic nurse- opportunities
client relationship for listening
conveying an to concerns
attitude of caring and
and developing questions
trust acknowledge
the individual as
someone
worthwhile

Encourage
verbalizations of
To enhance
and role play
handling of
anticipated
potential
 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
importance of
provide the
adequate nutrition
especially fluids, pt
protein, vit.C, vit.B, information
iron calories and on how
potassium rich nutrition
foods could elevate
her chances
of faster
recovery