Care Plan On Ileostomy and Colostomy

Ileostomy and Colostomy Nursing Care Plans An ileostomy is a gap built inside the terminal ileum to deal with regional and ulcerative colitis and to divert intestinal contents in colon cancer, polyps, and trauma. It is generally executed while the complete colon, rectum, and anus ought to be removed, in which case the ileostomy is permanent. A brief ileostomy is performed to offer entire bowel rest in situations including persistent colitis and in a few trauma cases. A colostomy is a diversion of the effluent of the colon and may be transient or everlasting. Ascending, transverse, and sigmoid colostomies can be finished. Transverse colostomy is usually brief. A sigmoid colostomy is the maximum commonplace everlasting stoma, generally accomplished for cancer remedy. Nursing Care Plans I.Risk for Impaired Skin Integrity Nursing Diagnosis  Risk for Impaired Skin Integrity Risk factors may include    Absence of sphincter at the stoma Character/flow of effluent and flatus from the stoma Reaction to product/chemicals; improper fitting/care of appliance/skin Possibly evidenced by  Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes    Client will maintain skin integrity around the stoma. Client will identify individual risk factors. Client will demonstrate behaviors/techniques to promote healing/prevent skin breakdown. Nursing Intervention Inspect stoma and peristomal skin location with each pouch exchange. Note inflammation, bruises (dark, bluish color), rashes 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. Measure stoma periodically: at least weekly for the first 6 wk., then once a month for six mo. Measure each width and duration of stoma. Verify that opening on the adhesive backing of the pouch is at the least 1⁄16 to Intervention Monitors the recovery procedure and effectiveness of home equipment and identifies areas of difficulty, and need for in addition evaluation, and intervention. Early identity of stomal necrosis or ischemia or fungal contamination (from changes in normal bowel vegetation) gives for well-timed interventions to save you critical headaches. The stoma should be purple and wet. Ulcerated regions on the stoma can be from a pouch commencing this is too small or a faceplate that cuts into the stoma. In sufferers with an ileostomy, the effluent is wealthy in enzymes, increasing the likelihood of skin infection. In sufferers with a colostomy, pores and skin care isn't as exquisite a problem because the enzymes are no longer present inside the effluent. Maintaining a clean and dry area helps prevent skin breakdown. 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. An ok at least one⁄8 in (2–3 mm) large than the bottom of the stoma, with good enough adhesiveness left to use pouch. adhesive place prevents the pores and skin barrier wafer from being too tight. Note: Too tight a in shape may also reason stomal edema or stenosis. Use a transparent, odor-proof drainable pouch. A transparent appliance during first 4–6 wk allows easy observation of stoma without necessity of removing pouch/irritating skin. Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Sigmoid colostomy may not require use of a skin barrier once stool becomes formed and elimination is regulated through irrigation. Frequent pouch modifications are irritating to the pores and skin and should be prevented. Emptying and rinsing the pouch with the right solution not only removes bacteria and odor-inflicting stool and flatus however additionally deodorizes the pouch. Prevents tissue irritation or destruction associated with “pulling” pouch off. Apply appropriate pores and skin barrier: hydrocolloid wafer, karaya gun, prolonged-wear pores and skin barrier, or comparable products. Empty, irrigate, and cleanse ostomy pouch on a routine basis, using appropriate equipment. Support surrounding skin when gently removing appliance. Apply adhesive removers as indicated, then wash thoroughly. Apply corticosteroid aerosol spray and prescribed antifungal powder as indicated. Consult with certified wound, ostomy, continence nurse. II. Disturbed Body Image Assists in healing if peristomal irritation persists and/or fungal infection develops. Note: These products can have potent side effects and should be used sparingly. Helpful in selecting merchandise suitable for affected person’s specific rehabilitation wishes, which includes form of ostomy, physical/intellectual repute, capabilities to deal with self-care, and monetary resources. Nursing Diagnosis  Disturbed Body Image May be related to  Biophysical: presence of stoma; loss of control of bowel elimination  Psychosocial: altered body structure  Disease process and associated treatment regimen, e.g., cancer, colitis Possibly evidenced by  Verbalization of change in body image, fear of rejection/reaction of others, and negative feelings about body.  Actual change in structure and/or function (ostomy).  Not touching/looking at stoma, refusal to participate in care. Desired Outcomes  Client will verbalize acceptance of self in situation, incorporating change into self-concept without negating self-esteem.  Client will demonstrate beginning acceptance by viewing/touching stoma and participating in self-care.  Client will verbalize feelings about stoma/illness; begin to deal constructively with situation. Nursing Intervention Rationale Ascertain whether or not aid and counseling had been initiated while the possibility and/or necessity of ostomy was first discussed. Encourage patient/SO to verbalize emotions regarding the ostomy. Acknowledge normality of feelings of anger, despair, and grief over a loss. Discuss each day “ups .And downs” which can occur. Plan/schedule care activities with the patient. Provides information about patient’s/SO’s level of knowledge and anxiety about an individual situation. Note behaviors of withdrawal increased dependency, manipulation, or noninvolvement in care Suggestive of problems in adjustment that may require further evaluation and more extensive therapy. III .Acute Pain Helps the patient realize that feelings are not unusual and that feeling guilty about them is not necessary or helpful. Patient needs to recognize feelings before they can be dealt with effectively. Promotes a experience of control and gives a message that patient can cope with the scenario, improving self-concept Nursing Diagnosis  Acute Pain May be related to  Physical factors: e.g., disruption of skin/tissues (incisions/drains)  Biological: activity of disease process (cancer, trauma)  Psychological factors: e.g., fear, anxiety Possibly evidenced by  Reports of pain, self-focusing  Guarding/distraction behaviors, restlessness  Autonomic responses, e.g., changes in vital signs Desired Outcomes  Client will verbalize that pain is relieved/controlled.  Client will display relief of pain, able to Sleep/rest appropriately  Client will demonstrate the use of relaxation skills and general comfort measures as indicated for an individual situation. NURSING INTERVENTION Assess pain, noting location, characteristics, intensity (0–10 scale). RATIONALE Pain in the anal area associated with abdominal-perineal resection may persist for months. Helps evaluate the degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or Provide sitz baths. Apply/monitor the effects of transcutaneous electrical nerve stimulator (TENS) unit. Administer medication as indicated, e.g., narcotics, analgesics, patientcontrolled analgesia (PCA). Encourage use of relaxation techniques, e.g., guided imagery, visualization. Provide diversional activities. Advise the patient to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with the patient, and giving appropriate information. Provide comfort measures, e.g., mouth care, back rub, repositioning (use proper support measures as needed). Assure patient that position change will not injure stoma Assist with ROM exercises and encourage early ambulation. Avoid prolonged sitting position. fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Relieves local discomfort, reduces edema, and promotes healing of perineal wound. Cutaneous stimulation may be used to block transmission of the pain stimulus Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair. Helps patient rest more effectively and refocuses attention, thereby reducing pain and discomfort. Reduction of anxiety/fear can promote relaxation or comfort. Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities. Reduces muscle/joint stiffness. Ambulation returns organs to normal position and promotes the return of usual level of functioning. IV.Impaired Skin Integrity Nursing Diagnosis  Impaired Skin Integrity May be related to  Invasion of body structure (e.g., perineal resection)  Stasis of secretions/drainage  Altered circulation, edema; malnutrition Possibly evidenced by  Disruption of skin/tissue: presence of incision and sutures, drains Desired Outcomes  Client will achieve timely wound healing free of signs of infection. NURSING INTERVENTION RATIONALE 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. Encourage side-lying position with the head elevated. Avoid prolonged sitting. Promotes drainage from perineal wound/drains, reducing the risk of pooling. Prolonged sitting increases perineal pressure, reducing circulation to wound, and may delay healing. Provide sitz baths. Promotes cleanliness and facilitates healing, especially after packing is removed Irrigate wound as indicated, using normal saline (NS), diluted hydrogen peroxide, or antibiotic solution. May be required to treat preoperative inflammation and/or infection or intraoperative contamination. Observe wounds, note characteristics of drainage. Depending on the type of wound closure (e.g., first or second intention), complete healing may take 6-8 mo. V.Risk for Deficient Fluid Volume Nursing Diagnosis  Risk for Deficient Fluid Volume Risk factors may include  Excessive losses through normal routes, e.g., preoperative emesis and diarrhea; high-volume ileostomy output.  Losses through abnormal routes, e.g., NG/intestinal tube, perineal wound drainage tubes.  Medically restricted intake.  Altered absorption of fluid, e.g., loss of colon function.  Hypermetabolic states, e.g., inflammation, healing process. Possibly evidenced by  Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes  Client will maintain adequate hydration as evidenced by moist mucous membranes, good skin turgor and capillary refill, stable vital signs, and individually appropriate urinary output. NURSING INTERVENTION RATIONALE Monitor intake and output (I&O) carefully, measure liquid stool. Weigh regularly. Provides direct indicators of fluid balance. Greatest fluid losses occur with an ileostomy, but they generally do not exceed 500–800 mL/day. Administer IV fluid and electrolytes as indicated. May be necessary to maintain adequate tissue perfusion/organ function. Limit intake of ice chips during the period of gastric intubation. Ice chips can stimulate gastric secretions and wash out electrolytes Monitor laboratory results, e.g., Hct and electrolytes Detects homeostasis or imbalance, and aids in determining replacement needs Risk for Sexual Dysfunction Nursing Diagnosis  Risk for Sexual Dysfunction Risk factors may include  Altered body structure/function; radical resection/treatment procedures  Vulnerability/psychological concern about response of SO  Disruption of sexual response pattern, e.g., erectile difficulty Possibly evidenced by  Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes  Client will verbalize understanding of relationship of physical condition to sexual problems.  Client will identify satisfying/acceptable sexual practices and explore alternative methods.  Client will resume sexual relationship as appropriate. NURSING INTERVENTION RATIONALE Reinforce the information given by the physician. Encourage questions. Provide additional information as needed. Reiteration of data previously given assists patient/SO to hear and process the knowledge again, moving toward acceptance of individual limitations or restrictions and prognosis (that it may take up to 2 yr to regain potency after a radical procedure or that a penile prosthesis may be necessary). Minimizing the awkwardness of appliance and physical discomfort can enhance satisfaction. Problem-solve alternative positions for coitus. Provide birth control information as appropriate and stress that impotence does not necessarily mean the patient is sterile. Confusion may exist that can lead to an unwanted pregnancy. Refer to sex counseling or therapy if appropriate. If problems persist longer than several months after surgery, a trained therapist may be required to facilitate communication between patient and SO. Rehearsal is helpful in dealing with actual situations when they arise, preventing self-consciousness about “different” body image. Discuss or role play possible interactions or approaches when dealing with new sexual partners. Stress awareness of factors that might be distracting VI.Disturbed Sleep Pattern Laughter can help individuals deal more effectively with a difficult situation, promote positive sexual experience. Nursing Diagnosis  Disturbed Sleep Pattern May be related to  External factors: necessity of ostomy care, excessive flatus/ostomy effluent  Internal factors: psychological stress, fear of leakage of pouch/injury to stoma Possibly evidenced by  Verbalizations of interrupted sleep, not feeling well rested  Changes in behavior, e.g., irritability, listlessness/lethargy Desired Outcomes  Client will sleep/rest between disturbances.  Client will report an increased sense of well-being and feeling rested. NURSING INTERVENTION RATIONALE Restrict intake of caffeine-containing foods or fluid Caffeine may delay the patient falling asleep and interfere with REM (rapid eye movement) sleep, resulting in patient not feeling well rested. Promotes relaxation and readiness for sleep. Patient is more apt to be tolerant of disturbances by staff if he or she understands the reasons for or importance of care. Pain can interfere with a patient’s ability to fall or remain asleep. Timely medication can enhance rest Support continuation of usual bedtime rituals Explain the necessity to monitor intestinal function in the early postoperative period. Administer analgesics, sedatives at bedtime as indicated and sleep during the initial postoperative period.