Nanda Books

Planning and Implementation

Objective

The main objective may include elimination of body waste products are adequate; reduction / elimination of pain; increased activity tolerance; obtain optimal levels of nutrients; maintain fluid and electrolyte balance; decreased anxiety; understand about the diagnosis, surgical procedures and self-care after discharge; maintain optimal tissue healing ; periostomal adequate skin protection; excavation and disclosure of feelings and problems of colostomy and its influence on the self.

1. Maintaining elimination
The frequency and consistency of bowel movements monitored.
Laxatives and enemas prescription.
Patients who show signs of progression toward total obstruction prepared for surgery.

2. Eliminate Pain
Analgesic prescription.
Environment is conducive to relaxation by dimming the lights, turning off the TV or radio, and limiting visitors and phone if desired by the patient.
Offer additional comfort measures: change of position, rubbing his back, and relaxation techniques.

3. Increasing Tolerance Activities
Assess the patient's level of tolerance activity.
Change and schedule activities to allow for an adequate period of bed rest in an attempt to reduce fatigue patients.
Komponendarah Therapy prescription when a patient suffering from severe anemia.
Improved postoperative activity and tolerance monitored.

4. Providing nutritional measures
If the patient's condition permits, a diet high in calories, protein, carbohydrates, and low preoperative residual given for several days to provide adequate nutrition and minimize peristaltic cramps by reducing excess.
Liquid Diet full 24 hours preoperatively, to replace nutrient depletion, vitamins and minerals.
Daily weighing is recorded, and the doctor notified when there is weight loss when receiving parenteral nutrition.

5. Maintaining Fluid and Electrolyte Balance
Record input and output, including vomiting, which will provide accurate data on fluid balance.
Limit entries oral food and fluids to prevent vomiting.
Give antiemetics as indicated.
Insert a nasogastric tube in the pre surgery to drain fluid and prevent the accumulation of abdominal distension.
Insert indwelling catheter to monitor urine output of every hour. Output of less than 30 ml / h was reported that intravenous fluid therapy can be adjusted.
Monitor and elktrolit IV fluids, especially serum to detect hypokalemia and hyponatremia, which occurs due to loss of gastrointestinal fluids.
Assess TTV to detect hypovolemia: tachycardia, hypotension and decreased number of beats.
Assess hydration status, decreased skin turgor, dry mucous membranes, concentrated urine, and urine specific gravity increased reported.

6. Lowers Anxiety
Assess the patient's level of anxiety and coping mechanisms used.
Efforts to provide support, including the provision of privacy when desired and instruct patients to practice relaxation.
Take time to listen to the phrase, sadness or questions raised by patients.
Set up a meeting with the pastor when the patient wants, the physician when the patient expects discussion of treatment or prognosis.
Another Stoma Patients may be asked to visit when the patient expressed an interest to talk to them.
To improve the comfort of patients, nurses must prioritize relaxation and behavioral empathy.

7. Prevent Infection
Give antibiotics such as kanamycin sulfate (Kantrex), erythromycin (erythromycin), and Neomycin Sulfate as prescribed, to reduce intestinal bacteria in preparation for bowel surgery.
Preparations given by mouth to reduce the bacterial content of the colon and soften and reduce the bulk of the contents of the colon.
Selian, the intestine can also be cleaned with enemas, or colonic irrigation.

8. Pre Operative
Assess the patient's level of need on diagnosis, prognosis, surgical procedures, and the desired level of function after surgery.
The required information about the patient's physical preparation for surgery, the appearance and maintenance of the expected post-op wound, colostomy care techniques, dietary restriction, pain control, and management of drug incorporated into the education material.