Question

How do I do a nursing care plan with this case scenario?

Mrs. Rose is a 51- year- old female who is admitted to the medical surgical unit following a resection of the sigmoid colon and rectum due to a cancerous growth. She has a colostomy.

Mrs. Rose is married, has three children - two daughters, age 29 and 26, who are living on their own approx. 2 hours away and a son, age 20, who is in university and living at home.

Mrs. Rose had been in good health until January of this year when she noticed a decrease in appetite, abnormal bowel movements, varying from small hard stools to loose watery stools, and a sudden drop in weight of 9 lbs over 4 weeks. Mrs. Rose stated she had not been on a diet, had always struggled with her weight and was secretly elated when she began to lose weight with no effort.

Mrs. Rose is on a blood pressure medication and takes vitamin D and Calcium po daily. She has no known allergies.

Doctor’s Orders post operatively include:

Vital signs q4h

AAT – ambulate daily

Diet – clear fluids for 12 hours then soft foods with low sodium

IV Normal Saline at 100 cc/hr

Medications:

Norvasc 5mg po OD

Calcium / Vitamin D supplements as per routine

Clean area around stoma 2x daily

Consult to Enterostomal therapy

Morphine 2.5 mg IV every 2 hours prn

Gravol 50 mg po q 4 hr prn

You are assigned total patient care for Mrs. Rose. She is now 19 hours post- operative. When you approach Mrs. Rose and introduce yourself, she nods but does not respond.

The patient has an IV #20 intercath infusing in the left forearm of Normal Saline at100 cc/hr.

She has a stoma protruding from the left side of the abdomen.

A stoma bag is covering the stoma and attached to the skin surrounding it.

During your initial assessment, Mrs. Rose begins to cry and says: “I can’t believe this is happening to me.” While you are providing personal care Mrs. Rose covers her head with the sheet.   

You examine the stoma, note that it is pink and oozing liquid stool into the stoma bag. You inform Mrs. Rose that the incision site is very clean and looks healthy. Mrs. Rose refuses to look at the stoma and tells you “I do not want to hear anything about this.”

A liquid diet was initially ordered but now soft foods have been ordered for Mrs. Rose. Mrs. Rose refuses the tray stating, “I’m not hungry.”

Mrs. Rose’s husband and son arrive after breakfast and are very concerned and attentive over her. She smiles and asks them several questions about their work and university. Her daughters will be arriving later in the day.

You explain to Mr. Rose that it is important to ambulate daily (as per Dr Orders) and that he and their son can certainly be there and assist. Mrs. Rose tells you she is in too much pain to get out of bed and perhaps it is better that her husband and son go home and come back later. You ask Mrs. Rose about the intensity of the pain. She says it is 7/10.

Later that day, Mrs. Rose appears flushed and you note the following assessment findings:

Temp 37.9,

HR 87,

BP 153/87,

R 20,

O2 saturation per pulse oximetry-100% on room air.

The skin around the stoma is red and appears irritated, the stoma is still pink, and draining a very soft slightly formed stool.

Answer 1

1) ans) Nursing diagnosis:

Risk for skin integrity related to Character/flow of effluent and flatus from the stoma as evidenced by patient condition.

Goal:

client will maintain skin integrity around the stoma.

Nursing interventions: Rationale

assess the patient condition- To know about the patient health status.

Inspect stoma and peristomal skin area with each pouch change. Note irritation, bruises dark, bluish color rashe. - Early identification of stomal necrosis

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

Support surrounding skin when gently removing appliance. Apply adhesive removers as indicated, then wash thoroughly. - Prevents tissue irritation or destruction associated with “pulling” pouch off.

Apply corticosteroid aerosol spray and antifungal powder as per physician order. -
Assists in healing if peristomal irritation persists and/or fungal infection develops.

Evaluation:

Client skin integrity may maintained.

2) Nursing diagnosis

acute pain related to disruption of skin/tissues incisions/drains as evidenced by reports of pain .

Goal:

Client will verbalize that pain is relieved/controlled.

Nursing interventions: Rationale

Assess pain, noting location, characteristics, intensity (0–10 scale). -Helps evaluate the degree of discomfort

Encourage patient to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with the patient, and giving appropriate information.  

-Reduction of anxiety/fear can promote relaxation or comfort.

Provide comfort measures, e.g., mouth care, back rub, repositioning . Assure patient that position change will not injure stoma.-

Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities.

Encourage use of relaxation techniques, e.g., guided imagery, visualization. Provide diversional activities.- Helps patient rest more effectively and refocuses attention, thereby reducing pain and discomfort

Administer medication as indicated, e.g., narcotics, analgesics, patient-controlled analgesia (PCA). -Relieves pain, enhances comfort, and promotes rest.

Evaluation:

Client pain may controlled