Nursing diagnosis Rank Impaired Skin Integrity related 1 to tissue trauma secondary to colostomy

Acute pain related to tissue trauma secondary to colostomy

Disturbed Sleep Pattern

Risk for fluid volume deficit related to altered absorption of fluid

Risk for infection related to open wound

Justification This is the first prioritized problem because when an open wound is not taken care properly it could get infected and lead to further problems like delayed healing. In Maslows hierarchy of needs this belongs to the second level which is the safety. Also this is an actual problem This is the 3rd prioritized problem because the client complaint of pain rated as 5/10 and this is the clients verbalization of the problem. In maslows hierarchy of need this belong to the physiologic need. This is the 2nd prioritized problem because when you dont have enough sleep it would stimulate the negative hormone in your body which affects your immune system making you more prone to diseases. This belongs to the physiologic needs of maslow. This is the 4th prioritized problem because it is a potential problem that when not prevented it could lead to dehydration which put the clients life in danger. In maslows hierarchy of needs this belongs to the physiologic needs This is the 5th problem because it is a potential

problem that when not prevented it could delay the wound healing of the patient. Other problems Imbalanced Nutrition Sexual Dysfunction

ASSESSMENT Problem= Impaired Skin Integrity related to tissue trauma secondary to colostomy O=

EXPLANATION A colostomy is a diversion of the effluent of the colon and may be temporary or permanent. Ascending, transverse, and sigmoid colostomies may be performed. Transverse colostomy is usually temporary. A sigmoid colostomy is the most common permanent stoma, usually performed for cancer treatment.

GOALS AND OBJECTIVES Goal= the client will maintain skin integrity around stoma. Objectives= -After 30 minutes of nursing intervention the client will; 1. Identify 2-3 ways to promote wound healing. 2. Identify 2 infection controls. After 3 hours of nursing intervention the client will not any signs of infection such as redness, itchiness and puss in the operative site.

INTERVENTIONS DIAGNOSTICS= -Inspect stoma/peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), rashes

RATIONALE

EVALUATION Fully met the client was able to identify 2 ways to promote wound healing and infection control Fully during the shift there are no signs of infection noted such as redness, itchiness and puss.

-Monitors healing process/effectiveness of appliances and identifies areas of concern, need for further evaluation/intervention. Early identification of stomal necrosis/ischemia or fungal infection (from changes in normal bowel flora) provides for timely interventions to prevent serious complications. Stoma should be red and moist. - As postoperative edema resolves (during first 6 wk), the stoma shrinks and size of appliance must be altered to ensure proper fit so that effluent is collected as it flows from the ostomy and contact with the skin is prevented. - Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area prevents the skin barrier

-Measure stoma periodically, e.g., at least weekly for first 6 wk, then once a month for 6 mo. Measure both width and length of stoma.

-Verify that opening on adhesive backing of

pouch is at least 116 to 18 in (23 mm) larger than the base of the stoma, with adequate adhesiveness left to apply pouch.

wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.

-Observe wounds, note characteristics of drainage.

-Postoperative hemorrhage is most likely to occur during first 48 hr, whereas infection may develop at any time. Depending on type of wound closure (e.g., first or second intention), complete healing may take 6-8 mo.

THERAPEUTIC= - Clean with warm water and pat dry. Use soap only if area is covered with sticky stool. If paste has collected on the skin, let it dry, then peel it off. -Support surrounding skin when gently

- Maintaining a clean/dry area helps prevent skin breakdown.

- Prevents tissue irritation/destruction associated with pulling pouch off.

removing appliance. Apply adhesive removers as indicated, then wash thoroughly. -Empty, irrigate, and cleanse ostomy pouch on a routine basis, using appropriate equipment. - Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with the proper solution not only removes bacteria and odor-causing stool and flatus but also deodorizes the pouch.

-Change dressings as needed using aseptic technique

- Large amounts of serous drainage require that dressings be changed frequently to reduce skin irritation and potential for infection. -Promotes drainage from perineal wound/drains, reducing risk of pooling. Prolonged sitting increases perineal pressure, reducing circulation to wound, and may delay healing.

EDUCATIVE= -Encourage side-lying position with head elevated. Avoid prolonged sitting.

-Indicative of effluent -Encouraged to reports leakage with peristomal of irritation, or burning/itching/blistering possibly Candida infection, around stoma. requiring intervention. - doing the proper hand would reduce the number of microorganism and chance of infection.

-Teach proper handwashing