tracts to skin elevated WBC count elevated sed rate soft tissue edema of

Tracts to skin elevated wbc count elevated sed rate

This preview shows page 139 - 142 out of 194 pages.

tracts to skin, elevated WBC count, elevated sed rate, soft tissue edema of surrounding area Nursing interventions/Teaching Monitor VS, monitor IV or oral antibiotic therapy, assess pain level frequently, use gentle handling and support when moving extremity, monitor the prescribed immobilization device and maintain patient’s body in correct alignment, teach patient to use assistive devices if able to ambulate, elevate extremity, teach patient about using distraction relaxation and breathing, teach patient about proper diet and physical rehabilitation, ROM on extremity, monitor for footdrop, Complications Septicemia, septic arthritis, pathologic fractures, squamous cell carcinoma, amyloidosis
140 Ostomy care (continent diversion) Definition Assessment- inspect stoma with pouch change (should be moist and red), measure stoma (shrinkage), VS, pain, body image/altered feelings of self,I&O, lab values, electrolytes, weight, bowel sounds S/S N/A Nursing interventions/Teaching Implement- clean with warm water and dry, adhesive backing 1/16 to 1/8 inch larger than stoma base, transparent/odor proof pouch, irrigate and cleanse periodically, consult with ostomy nurse, aseptic technique with bandaged wounds Education- future expectations, changing ostomy bag, signs/Sx of infection and skin break down, increase fluid intake Complications Skin breakdown, infection, disturbed body image
141 Ostomy – Ileostomy (Lippincott 590-94 & lewis1085-6) Definition: A surgical procedure in which an opening is made to allow passage of intestinal contents from the bowel to the incision/stoma. The stoma (opening surface of abd) is created when the intestine is brought through the abd wall and sutured to the skin, where fecal matter is diverted through. It may be permanent or temporary. There are various types: 1. Ileostomy – opening from ileum to through abd wall. ( aka conventional or Brooke Ileostomy) 2. Cecostomy – opening from cecum to abd wall. (uncommon, as well as ascending colon) are usually temporary. 3. Colostomy- opening between colon and abd wall. Proximal end of colon sutured to the skin. Ileostomy: Stool consistency – liquid to semi liquid Fluid requirement – increased Bowel regulation – no Pouch and skin barriers – yes Irrigation – no Indications for surgery: – ulcerative colitis, Cohn’s, diseased colon, birth defect, familial polypsis, Complications: stomal ischemia, stricture, or stenosis stomal prolapse peristomal hernia peristomal skin breakdown mucocutanious separation ( between skin and stoma) Nursing Interventions: educating patient – surgical procedure, Ostomy teaching, include fam, clarify misunderstanding promote positive self image reduce anxiety – gradual steps toward independent care maintain skin integrity – emptying 1/3 to ½ full maximize nutritional intake – avoid foods stimulate elimination, consistent moderate diet habits, nutritionist consult, weigh QD achieving sexual well being – discuss ways to conceal pouch, diff positions, counseling Characteristics of stomas: - pink, red, moist, bleeds slightly when rubbed, no felling to touch, stool functions involuntary, post op swelling decreased over several months.

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