OF UNIVERSITY KENTUCKY COLLEGE OF NURSING NUR 863: PROFESSIONAL NURSING CARE ACROSS THE LIFESPAN INTERACTIVE CARE PLAN WORKSHEET Student Name: _____Macy Bundy_______ Mailbox___291_____ Patient's Initials: S.O. Ht.: 6'1" Objective Data Entry BP: 118/68 (Normal) HR: 90 (Normal) RR: 14 (Normal) Temp: 98.2 (Normal) SaO2: 97% (Normal) Assessment: Abdomen soft, non tender, no palpable masses, normoactive bowel sounds x 4 quadrants, use of depends, stoma surrounded with erythemous and inflamed skin, colostomy full with soft stool, lack of sensation to recognize the urge to defecate, decreased muscle strength (0/5) bilaterally below T6, diet full of saturated fats, unable to change own colostomy bag, confusion with some disorientation, unable to follow through with directives, not able to listen attentively and distracted easily. (Normal= No use of depends undergarments; able to have a bowel movement that distends from small intestines through large intestines, if has a colostomy should be less than half full with surrounding skin intact; able to identify areas of light, sharp, and dull touch all over body; muscle strength (3-5)/5; consumes 2-3 dairy products, 2-3 meats, 2-4 fruits, 3-5 vegetables, and 6-11 grains per day; with colostomy bag ability to change by patient gives person autonomy; expresses full and free flowing thoughts during interview, follows directions accurately, listens and responds with full thoughts.)
Student Instructions: To be sure your patient diagnostic statement written below is accurate, you need to review the defining characteristics and related factors associated with the nursing diagnosis and see how your patient data match.
Patient's Medical Diagnosis: Paraplegic, functional decline, bilateral ischial wounds, encephalitis Sex: Male Age: 60 Wt.: 225
STUDENT INSTRUCTIONS:
In the space below enter the subjective and objective data related to the nursing diagnosis. Are the findings normal or abnormal? If abnormal include normal values for comparison.
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Subjective Data Entry Character of stool soft Constipation No history of bleeding, hemorrhoids, use of laxative, or diarrhea "It seems to get pretty full before they change it." "I don't eat those foods."
TIME OUT!
ASSESSMENT
DIAGNOSIS
PATIENT DIAGNOSTIC STATEMENT:
Nursing Diagnosis (specify): Bowel Incontinence Related to: cognitive impairment secondary to encephalitis AEB (as evidenced by): lack of sensation to recognize the urge to defecate, decreased muscle strength (0/5) below T6, full colostomy bag The client will: (overall goal): demonstrate an overall improvement in bowel care by discharge. Outcome criteria: 1. The client will verbalize specific foods he can eat to help increase his number of bowel movements within two days of teaching. 2. The client's skin surrounding the stoma will show an improvement of integrity though a decreased amount of inflammation and erythema within one week of skin care being performed. 3. The client's wife will demonstrate to the nurse how to empty and change the colostomy in bag, addition to how often to perform care with in one week of teaching.
Desired Outcome and Patient Criteria: PLANNING
TIME OUT!
The outcome must be specific, realistic, measurable, and include a time frame for completion. Does the action verb describe the patient's behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the patient's response to the nursing interventions listed below.
Interventions 1. The nurse will asses the clients dietary intake promoting things high in soluble and insoluble fiber including: oatmeal (S), fruits (S&I), legumes (S), vegetables (S&I), nuts (I), popcorn (I), and brown rice (I). PLANNING 2. The nurse will provide skin care around client's stoma every time his colostomy bag is changed. 3. The nurse will teach the clients wife to empty the colostomy bag on a regular basis and to change the colostomy bag at least every 3 days.
Rationale for Selected Intervention and References 1. "Dietary fiber increase the weight and water content of feces. It also speeds the progress of feces through the GI tract. Water retained by fiber softens the stool and promotes regularity. Thus supplementing diets with bran, whole-grain cereals, nuts, and raw fruits and vegetables is effective in promoting normal bowel elimination." (Harkreader, Hogan, Thobaben., 2007 p. 734) 2. "The main goal is to prevent prolonged contact between the skin and fecal material, which leads to skin breakdown." (Harkreader, Hogan, Thobaben., 2007 p. 741) 3. Ostomies continually drain fecal material with the exception of continent ileostomies. Stool must be emptied on a regular basis to promote good patient health and cleanliness, as well as, must be changed to assess for and provide overall skin integrity. (Harkreader, Hogan, Thobaben., 2007)
What was your patient's response to the interventions? 1. The client verbalized back to the nurse specific foods to look for and include in his diet to promote regular bowel movements. He includes bran, whole-grain cereal, nuts and raw fruits and vegetables. 2. The client's skin showed a decrease in erythamous and inflammation around his stoma providing evidence of improved skin integrity. She used soap and water making sure the area was thoroughly dried before the soma wafer was replaced. 3. The client's wife demonstrated back to the nurse how to empty and change the colostomy bag, as well as, when to do so. She explained the bag needed to be emptied regularly and that it must be replaced at least every 3 days or if it became lose.
Was the desired outcome achieved? All desired outcomes were achieved Yes _No
If no, what revisions to either the desired outcome or interventions would you make?
INSTRUCTOR'S COMMENTS:
Harkreader. H., Hogan, M., & Thobaben, M. (2007). Fundamentals of nursing: Caring and clinical judgment. St. Louis: Saunders Elsevier.
Weber, Janet R. (2005). Nurses' Handbook of Health Assessment. St. Louis Missouri: Lippincott Williams & Wilkins.
CD/lm N863careplan 8/28/06