Saint Joseph College Institute of Health Sciences Cavite City NURSING Name: Mario Braga Impression: s/p colectomy

Cues/Evide nces Subjective: Objective: Fluid imbalance: Hypovolemi a PR=108 bpm BP=110/64 mmHg ASSESSMENT Nursing Diagnosis Risk for electrolyte imbalance (specificall y hypernatre mia and hyperkale mia) Scientific Rationale Age: 50 y/o PLANNING Nursing Objective Within 3-4 hrs. of giving nursing intervention, the client will Be free of complications resulting from electrolyte imbalance as manifested by: Display vital signs and laboratory results within normal range for individual. Identify individual risks and engage in appropriate behaviors or lifestyle changes to prevent or reduce frequency of electrolyte imbalances. CARE PLAN Sex: M IMPLEMENTATION Nursing Scientific Order/Action Rationale Identify client with current or newly diagnosed condition commonly associated with electrolyte imbalances, such as inability to eat or drink febrile illness, active bleeding or other fluid loss, including vomiting, diarrhea, gastrointestinal drainage, burns. Note clients age and developmental level, which may increase risk for electrolyte imbalance. to further assess the client and prevent more serious complications

EVALUATIO N

Elderly clients are more prone to electrolyte imbalances related to fluid imbalances, use of multiple medications including diuretics, heart and blood pressure medications, lack of appetite or interest in eating or drinking, lack of appropriate dietary and/or medication supervision at home,

and so on. It is the most common Assess mental problem of status, noting hypernatremia. client/caregiver report of change altered attention span, recall of recent events, other Cognitive functions. Tachycardia, bradycardia, and other Monitor heart rate dysrhythmias are and rhythm by associated with palpation and potassium, calcium, and auscultation. magnesium imbalances. Because the ECG reflects electrophysiological, anatomical, metabolic, and hemodynamic alterations, it is routinely used for the diagnosis of electrolyte and metabolic disturbances, as well as myocardial ischemia, cardiac dysrhythmias, structural changes of the myocardium, and drug effects.

Review electrocardiogram (ECG).

Assess fluid intake Many factors, such as and output. inability to drink, large diuresis or chronic kidney failure, trauma, and surgery, affect individuals fluid balance, disrupting electrolyte transport,

function, and excretion. Review laboratory results for abnormal findings Electrolytes include sodium, potassium, calcium, chloride, bicarbonate (carbon dioxide) and magnesium. These chemicals are essential in many bodily functions including fluid balance, movement of fluid within and between body Na+ compartments, nerve Monitor for physical conduction, muscle or mental disorders contraction including impacting fluid the heart; blood clotting intake and pH balance. Impaired thirst Note presence of sensation, inability to medical conditions express thirst or obtain that may impact needed fluids may lead sodium level. to hypernatremia. Hypernatremia can result from simple conditions such as febrile illness causing fluid loss and/or restricted fluid intake, or complicated conditions such as kidney and endocrine diseases affecting sodium intake or excretion. Diuretics, laxatives,

Review regimen.

drug

K+ Note current medical conditions that may impact potassium level.

theophylline, and trimeterine can decrease sodium level. Metabolic acidosis, burn or crush injuries, Monitor ECG, as massive hemolysis, indicated diabetes, kidney disease/renal failure, cancer, and sickle cell trait are associated with Evaluate reports hyperkalemia of abdominal cramping, Abnormal potassium fatigue, levels, both low and hyperactive high, are associated bowel motility, with changes in the muscle twitching, ECG. and cramps, followed by Signs/ symptoms muscle suggesting weakness. Note hyperkalemia. presence of depressed reflexes, ascending flaccid paralysis of legs and arms. Review regimen. drug Medications such as albuterol, terbutaline, or some diuretics may decrease potassium level.

Cues/Evide nces Subjective: Objective: The client undergoes colectomy 2 days ago Presence of incision site Pus and redness is not indicted

ASSESSMENT Nursing Diagnosis Risk for infection related to a site for organism invasion secondary to colectomy 2 days ago as manifested by Presence of incision site and Pus and redness is not indicted

Scientific Rationale

PLANNING Nursing Objective Within 1-2 hrs of giving intervention, the client will be able to identify behaviors and practices to prevent and reduce the risk for infection as manifested by:

IMPLEMENTATION Nursing Scientific Order/Action Rationale Independent: Monitor white blood count (WBC). Rising WBC indicates the bodys attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured. Hand washing reduces the risk of transmitting pathogens from one area of the body to another as well as from one patient to another. Prevents entry of bacteria, reducing risk of nosocomial infections.

EVALUATIO N

Demonstrate meticulous hand Stress and model washing proper handtechnique by the washing technique time of discharge to client and caregivers. Describe methods of transmission of infection Maintain aseptic technique with any Describe the procedures. Provide influence of routine site nutrition on care/wound care, as prevention of

Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection.

infection. appropriate. Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications. Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.

Inspect dressings and wound; note characteristics of drainage. Encourage frequent position changes and being out of bed or ambulation, as tolerated. Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.

Reduces bacterial colonization and risk of ascending UTI.

Monitor vital signs.

Temperature elevation and tachycardia may reflect developing sepsis.

Collaborative: Encourage intake of protein and calorie rich foods.

Optimal nutritional status promotes wound

healing. Administer antibiotics, as indicated. All agents are either toxic to the pathogens or retard the pathogens growth. Ideally medications should be selected based on a culture from the infected area. A broad-spectrum agent may be started until culture reports are available.

Cues/Evide nces Subjective: Objective: Disruption of epidermal and dermal tissues: presence of surgical incision The client undergoes colectomy 2 days ago +2 edema Decreased blood pressure 110/64 mm Hg No other data about pus drainage and redness in the incision site

ASSESSMENT Nursing Diagnosis Impaired skin integrity related to post surgical wound and decreased blood and nutrients to tissues secondary to edema as manifested by: presence of surgical incision The client undergoes colectomy 2 days ago +2 edema Decreased blood pressure 110/64 mm Hg

Scientific Rationale

PLANNING Nursing Objective Within 1 hr of giving nursing intervention, the client will demonstrate progressive healing of tissue as manifested by: Participate in risk assessment Express willingness to participate in prevention of pressure ulcers. Describe etiology and preventive measures

IMPLEMENTATION Nursing Scientific Order/Action Rationale Observe wound, note characteristic of drainage. Change dressings, as needed using aseptict echnique Postoperative hemorrhage is most likely to occur during first48 hours whereas infection may develop at anytime. Large amount of serous drainage require that dressings, be change frequently to reduce skin irritation potential for infection May required treating preoperative inflammation or intra operative contamination To stimulate circulation

EVALUATIO N

Irrigate wound as indicated, using normal saline diluted with antibiotic solution Gently massage healthy skin around the affected site

Increase protein and To maintain nitrogen carbohydrate intake balance

Administer meds. as indicated.(antibiotic)

Antibiotic is the drug used to treat and prevent infection caused by bacteria.

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