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 Short Term:
O: The pt deficiencies -after 3 hours of rapport client’s trust -after 3 hours of
manifested: IMBALANCED primarily affects nursing and nursing
 Low NUTRITION; LESS gastrointestinal interventions the cooperation interventions the
plasma THAN BODY disorder or due patient will  Monitor and patient shall
level (2.73 REQUIREMENT to the verbalize record vital  To obtain verbalize
meqs/L) R/T INSUFFICIENT procedures prior understanding of signs baseline data understanding of
 BMI INTAKE OF FOOD and after causative factors causative factors
(16.56) RICH IN surgeries, in the and necessary  Assess general and necessary
 Presence POTASSIUM AND case of the pt, interventions to condition  To determine interventions to
of stoma in INTESTINAL she is required to promote interventions promote
the right DISTURBANCES empty the bowel optimum needed by the optimum
lower and be placed on nutrition. client nutrition.
quadrant low residue diet  Determining
of the for several days Long Term: precipitating  Identification Long Term:
abdomen before the -after 8 hours of factors and -after 8 hours of
surgery then nursing management nursing
The pt may nothing by interventions the of underlying interventions the
manifest: mouth so as a patient will cause is patient shall
 Muscle result nutritional demonstrate essential to demonstrate
weakness status of the pt is behaviour recovery behaviour
 Fatigue much likely changes to  Assess ability changes to
 Fall, injury, affected regain weight to chew, taste  These may regain weight
seizures including her from BMI of and swallow limit client’s from BMI of
plasma 16.56 to 18. ability to 16.56 to 18.
potassium level. ingest food
 Auscultate and reducing
bowel sounds desire to eat
 Hypermotility
of intestinal
tract is
common and
is associated
with vomiting
and diarrhea
which may
affect choice
 Weigh as of diet/route
indicated,
evaluate  Indicator of
weight in nutritional
terms of needs and
premorbid adequacy of
weight intake
compare serial
weights and
anthropometri
c measures
 Plan diet with
client and SO,  Including the
 incorporating pt in planning
foods that gives a sense
client’s want of control of
or food from environment
home and may
enhance
intake
 Encouraged
small frequent  Fulfilling
meals and cravings for
snacks of desired food
nutritionally may also
dense and improve
non-acidic intake
foods

 Discussed the
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
 Instructed the
pt to limit
foods that
include nausea  To diminish
and vomiting, gastric
avoid serving irritants that
very hot and may cause
spicy foods client to be
reluctant to
 Schedule eat
medications
between
meals if
tolerated and  Gastric
limit fluid fullness
intake with diminishes
meals unless appetite and
fluid has food intake
nutritional
value

 Keep strict
documentation
of intake
output and
calorie count  It is necessary
to make an
Dependent: accurate
nutritional
 Administer assessment
medications as
indicated and
ordered for
example  Reduces
antiemetics incidence of
nausea and
vomiting
 Administer possibly
vitamin and enhancing
mineral oral intake
supplements
as ordered by  To increase
the physician nutritional
intake
Interdependent:

 In
collaboration
with the
dietician,
determine  To provide
number of adequate
calories nutrition and
required to realistic
 provide weight gain
adequate
nutrition and
realistic
weight gain

IMPAIRED SKIN INTEGRITY R/T MECHANICAL FACTORS 20colostomy

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: ǿ A colostomy is a Short Term:  Establish  To gain Short Term:
O: The pt surgical -after 2 hours of rapport client’s trust -after 2 hours of
manifested: IMPAIRED SKIN procedure that nursing and nursing
 Presence of INTEGRITY R/T brings a portion interventions the cooperation interventions the
stoma in MECHANICAL of the large patient will  Monitor and patient shall
the right FACTORS 20 intestine through participate in record vital  To obtain participate in
lower colostomy the abdominal prevention signs baseline data prevention
quadrant of wall to carry out measures and measures and
the feces out of the treatment  Assess treatment
 To determine
abdomen body. In the case program. general program.
interventions
of the pt condition
needed by the
The pt may temporary Long Term: Long Term:
client
manifest: colostomy are -after 2 days of -after 2 days of
 Pain, created to divert nursing nursing
itchiness stool from injured interventions the  Assess skin,  Establish interventions the
swelling of or diseased patient will noted color, comparative patient shall
the skin portion of the demonstrate turgor baseline demonstrate
around the large intestine, increase self- sensation; providing increased self-
stoma allowing rest and esteem AEB described and opportunity esteem AEB
 infection healing. It is done changing stoma measured for timely changing stoma
by accurate pouch stoma and intervention pouch
depiction of independently observed independently
colorectal surgery and promote changes and promote
beginning with a timely wound  Instruct family  Skin friction timely wound
midline incision, healing. to maintain caused by stiff healing.
then colon is cut clean and dry or rough
to allow insertion clothes clothes leads
of a catheter, the preferably to irritation
skin and tissues cotton fabric and increases
then are closed risk for
around the new infection
opening called  Instruct the pt
stoma. that the  To provide
peristomal proper ostomy
area should be care and
cleaned well prevent
with a mild complications
soap and
dried before
the new pouch
 is applied

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

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

 Instruct the pt
in stoma
assessment  Necessary to
and provided gather more
mechanism data
for concerning
documenting the pt
condition thus,
identifying
skin problem
and promoting
self-esteem
 Discuss pain
control if  To help pt
needed coop towards
proper pain
management,
thus
minimizing
suffering
RISK FOR INJURY R/T PRESENCE OF STOMA 20HYPOKALEMIA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: ǿ Because Short Term:  Establish  To gain Short Term:
O: The pt potassium is -after 4 hours of rapport client’s 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 STOMA 20 conduction and patient will  Monitor and patient shall
the right HYPOKALEMIA muscle function, demonstrate record vital  To obtain demonstrate
lower low plasma behaviours to signs baseline data behaviours to
quadrant of potassium level reduce risk reduce risk
the often lead to falls factors and  Assess factors and
 To determine
abdomen and seizures due protect self from general protect self from
interventions
 Low to the procedures injury. condition injury
needed by the
potassium prior and after
client
level (2.73 colostomy, the pt Long Term: Long Term:
meqs/L) is required to -after 1 week of -after 1 week of
 Identification
empty the bowel nursing  Determining nursing
and
The pt may and be placed on interventions the precipitating interventions the
manifest: low residue diet patient will be factors management patient shall be
 Muscle for several days free from injury of underlying free from injury
weakness before the and potassium cause is and potassium
 Falls and surgery then level will reach essential to level shall reach
seizures nothing by mouth the normal range. recovery the normal range
so as a result low
potassium level is  Ascertain  To prevent
caused by knowledge of injury from
decrease food safety needs/ home
intake. injury
prevention
and
motivation

 To prevent
 Put the bed on
risk for falls
lowest
position
 To meet the
needs without

 Develop plan injuries

of care within
the family to
meet pt’s
needs
 To prevent
injury and falls
 Make sure
before the pt
 walks, clear
the path of
obstacles and
place non-
slippery  These provide
shoes/slipper the pt
information on
 Discuss the
how nutrition
importance of
could elevate
adequate
her chances of
nutrition
faster
especially
recovery
fluids, protein,
vit.C, vit.B,
iron calories
and potassium
rich foods

DEPENDENT:
 To increase

 Administer or plasma

give oral/iv potassium

potassium as level of the

prescribed body

ensuring that
it is diluted in
IV fluids it
 can’t be given
as IV push

INTERDEPENDEN
T:  To allow more
accurate
 Notify the interventions
physician if to the pt
signs of
hypokalemia
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 Short Term:  Establish  To gain client’s 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 interventions the
stoma in DISRUPTED SKIN skin integrity may patient will  Monitor and  To obtain patient shall
the right INTEGRITY AFTER act on a portal of demonstrate record vital baseline data demonstrate
lower SURGERY AND entry by techniques/ signs techniques/
quadrant of PRESENCE OF opportunistic lifestyle changes lifestyle changes
 To determine
the STOMA microorganisms to promote safe  Assess to promote safe
interventions
abdomen from the environment. general environment.
needed by the
 Dry and environment. As condition
client
intact the healing Long Term: Long Term:
midline occurs, -after 2 days of -after 2 days of
incision of microorganisms nursing nursing
 the can inhibit the interventions the  Note risk  To help the interventions the
abdomen soiled stained patient will learn factors of client identify patient shall learn
for about with blood. This how to do having the present risk how to do
5-6 inches may cause interventions on infection in factors that lead interventions on
 Presence of interruption to how to prevent or the incision to infection how to prevent or
transverse the healing reduce the risk of site and stoma reduce the risk of
cut due to process and can infection and  To help the pt infection and
CS cause infection promote timely  Make health modify or avoid promote timely
 Incease on the operation wound healing. teachings in environmental wound healing.
WBC count site failure to identification factors that
(11.6×109 observe good of could prevent

/L) personal hygiene environmental infection

can predispose a risk factors

The pt may person to that could

manifest: infection. lead to

 Fever infection

 Pain,  A first line

itchiness defence against

 Stress proper
and infection
hand hygiene
swelling
among all
over the
caregivers, SO
peristomal
and to the pt
skin/incisio  To limit

n area exposure thus

 Monitor pt’s
 Redness reduce
visitors
over the contamination

incision site
  To reduce
 Recommend bacterial
routine or colonizaon
preoperative
body showers
 Skin friction
 Instruct family caused by stiff
to maintain or rough clothes
clean and dry leads to
clothes irritation and
preferably increases risk
cotton fabric for infection

 Instruct the pt  To provide

that the proper ostomy
peristomal care and
area should prevent
be cleaned complications
well 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

to empty the should
pouch when it demonstrate the
is about half ability to empty
full and teach and change the
on how to pouch
clean out the independently
pouch before being
properly when discharge
emptying it

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

DISTURBED BODY IMAGE R/T BIOPHYSICAL 20 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 alterations in nursing and nursing
 Presence of BODY IMAGE self-concept and interventions cooperation interventions
stoma in the R/T body image. the patient will the patient shall
right lower BIOPHYSICAL 20 This body image be able to  Monitor and record  To obtain be able to
quadrant of COLOSTOMY is the attitude a verbalize vital signs baseline data verbalize
the abdomen person has understanding understanding of
 Dry and about the actual of body image body image
 To determine
intact midline /perceived changes.  Assess general changes.
interventions
incision of structure or condition
needed by
the abdomen function of all or Long Term: Long Term:
the client
for about 5-6 part of the body. -after 2 days of -after 2 days of
inches This attitude is nursing nursing
 The extent of
 Naming dynamic and is interventions  Assess perception interventions
response is
changed altered through the patient will of change in the patient shall
more related
body part or interaction with demonstrate structure or demonstrate
to the value
function other people and enhance function of body and enhance
 BMI of 16.56 and situations body image and part of body image and
(underweight as an important self-esteem AEB importance self-esteem AEB
) part of one’s ability to look at/ the pt places ability to look at/
self concept. talk about and on the talk about and
Body image care for actual part/function care for actual
disturbance can altered body than actual altered body
have profound part/function. value part/function.
impact on how
individual view
 To
their overall  Assess perceived
determined
self. impact of change
how the pt
on activities of
act to
daily living social
changes
behaviour and
personal
responsibilities

 It may
 Evaluate level of
indicate
pt’s knowledge of
acceptance
and anxiety r/t
or non-
situation; observe
acceptance
emotional changes
of situation

 To evaluate
 Note signs of need for
grieving/ indicators counselling
 of severe and/or
depression medications
 May
influence
 Determine ethnic how
background and individual
cultural perceptions deals with
and considerations what
happened

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

 Provides
opportunities
 Establish for listening
 therapeutic nurse- to concerns
client relationship and
conveying an questions
attitude of caring
and developing
trust acknowledge
the individual as
someone
worthwhile
 To enhance
 Encourage handling of
verbalizations of potential
and role play situations
anticipated
conflicts  To begin
incorporate
 Encourage the changes into
client to use denial body image
without
participating  To minimize
body
 Help the client to changes and
select and use enhance
clothing/make up appearance

 To allow
easier
 Provide information assimilations
at clients level of
acceptance and is
small pieces, clarify
misconception  To provide
early/
 Begin counselling/ ongoing
other sources of
therapies(biofeedb support
ack/ relaxation
 These
provide the
 Discuss the
pt
importance of
information
adequate nutrition
on how
especially fluids,
nutrition
protein, vit.C, vit.B,
could elevate
iron calories and
her chances
potassium rich
of faster
foods
recovery