NCP - Impaired Skin
NCP - Impaired Skin
NCP - Impaired Skin
INTESTINAL DISTURBANCES
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
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
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
DEPENDENT:
Administer or
give oral/iv To increase
potassium as plasma
prescribed potassium
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
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
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