Methodist University

Professional Nursing Studies

NURSING CARE SUMMARY

Instructor: Cheryl Triplett

Date: 18 November 2016
Responsible Party: Medicaid
Students Name: Alyssa ONeill

Primary Diagnosis: Foreign body in rectum

Pertinent Diagnosis from Past Medical History: Hypertension, Sleep apnea

Age: 20 Sex: Male Race: African American

Religion: None Date Admitted: 15 November 2016
Occupation: Unemployed Family Role: Son; Single
Ht: 183 cm Wt: 135 kg
Current VS: Oral temperature 98.2F, Pulse 128, Respirations 18 breaths/min, Blood Pressure 148/101 Left Arm, Pulse
Oximetry 97% on Room Air
Adm. VS: Oral temperature 98.3F, Pulse 89, Respirations 18 breaths/min, Blood Pressure 129/80 Left Arm, Pulse
Oximetry 99% on Room Air
Allergies (In Red): Latex

Introduction: (Recent illnesses, chief complaint, use of alcohol or tobacco, psychosocial)

PT admitted with a foreign body lodged in his colon. PT stated he personally placed the object in his rectum. PT states it
was for sexual pleasure. PT identifies as being bisexual. PT stated his parents do not know he is bisexual, but would not
mind if he had to tell them. PT stated that it would be difficult to tell his parents that he was bisexual. PT was brought to the
hospital by his father. PT states that his father probably knows he is bisexual because of the events causing his admittance.
PT lives with his father, step-mother and sibling in an apartment. PT has two younger brothers. PT shares one bedroom with
his brothers. PT has two step-siblings; one older brother and one younger sister. PT has known his step-sister since he was
in 7th grade. PT states he used to like his step-sister, but they are not close any more. PT states that his step-sister knows
he is bisexual. PT states his step-mom is Puerto Rican and that he identifies with that culture. PT states that his step-mom
cooks well. PT states that he does not cook because others cook for him. PT denies any religious affiliation or church
attendance. PT denies use of alcohol or tobacco. PT likes to play video games, watch TV and movies, edit videos, and play
on the computer. PT denies the use of any medications.

Doorway Picture: (General appearance of the patient include: sights, sounds, odors, etc.; equipment in room, etc.)

PTs room is cool and dark. PT lays flat on his bed. PT often covers his eyes with his arms. PT uses one sheet. PT is
awake, alert and oriented. PT appears his stated age. PT often appears embarrassed. PT falls asleep easy. PT displays
facial grimacing and often grips his bed rails. PT constantly drinks from his water cup, but denies experiencing chronic thirst.
PT has an untouched food tray next to his bed. PT is attached to an IV. PT room has a normal, non-pungent odor. PT has a
bucket next to his bed for vomiting. PT has his gown mostly off. PT states he feels hot. PT can move himself up and bed
and easily reposition himself. PT needs assistance with his bath and had one last night. During the day, PT utilizes a
bedside urinal. PT has a short shallow breathing pattern. PT received a personal call to check on him. PT called for his pain
meds because he experiences pain with the catheter in his colostomy to decrease gas.
Head to Toe Assessment: (Write in narrative form)
Head (hair, eyes, nose, ear, mouth, etc.)

Head is symmetric, round, erect, midline, and normocephalic. Head is hard and smooth without lesions. Scalp is clean and
dry. Hair is dark, with normal texture, distribution and shine. Temporal artery is elastic, nontender. No swelling, tenderness,
crepitation of TMJ. Normal TMJ ROM. Frontal and maxillary sinus are nontender and free of crepitus. Moderate length, well-
groomed beard present. CN V, VII, IX, X intact.

Visual acuity is intact. CN II, III, IV, VI intact. Eye movement is smooth and symmetrical. Upper and lower eyelids close
easily and meet when closed. Skin on eyelids is negative for redness, swelling or lesions. Eyeballs are symmetrically
aligned in sockets. Bulbar conjunctiva is clear, moist and smooth. Sclera is white. Palpebral conjunctiva is without swelling
or lesions. No swelling, redness or drainage of the lacrimal apparatus. Iris is round, flat, evenly colored. Pupils are round,
centered in iris and equal in size. Pupils equally reactive to light.

Ears are equal bilateral. Auricle is appropriately positioned. Earlobes are free handing. Skin is smooth, free of lesions and
lumps. No discharge present. Auricle, tragus and mastoid process nontender. Moderate cerumen present, yellow in color.
Canal walls are pink and smooth, free of lesions.

Nose is symmetrical and nontender. Nasal mucosa is dark pink, moist and free of exudate. Septum is intact. Nasal cavity is
free of lesions. Nasal cavity has moderate amount of hair present.

Lips, mouth, and oral mucosa pink and free of swelling or lesions. Teeth are whitish and aligned. Tongue is pink, moist,
moderately sized with papillae. No unusual or foul odor noted. Uvula is pink, midline and symmetrical. Tonsils are pink,
symmetrical and 1+. Throat is pink and dree of lesions. No nasal flaring or pursed lip noted.

Neck (lymph nodes, trachea, carotids, veins, etc.)

Neck is symmetrical with no bulging masses. Thyroid nonpalpable. Normal neck movement, smooth and controlled. Trachea
midline. No bruit auscultated. No swelling, enlargement or tenderness of lymph nodes.

JVP not visible. Carotid pulse equal bilaterally, 2+. Carotid elastic and without thrills or bruit.

Chest (Apical pulse, lung sounds, breasts, respirations, etc.)

Apical pulse present and palpable. No pulsations or vibrations palpated in apex, left sternal border or base. Regular rate
and rhythm. S1 and S2 easily auscultated. No extra heart sounds noted. No murmurs present. Dullness noted over the heart.

Skin tone even with sparse chest hair. Moderate obesity. ATP diameter 1:2. Sternum straight and positioned midline. No
tenderness, pain or unusual sensations noted. No retractions noted. Ribs slope downward with symmetrical intercostal
spaces. Respirations are short and shallow. No retraction or bulging of intercostal spaces noted. Temperature cool and
equal bilaterally. No tenderness or pain palpated. No crepitus noted. No lesions or masses noted. Resonance noted over
thoracic cavity. Dullness noted over breast tissue. Flatness noted over ribs and sternum. No adventitious sounds
auscultated.

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Upper Extremities (ROM, strength, handgrips, pulses, etc.)

Evenly colored skin tone without unusual discolorations. No odor noted. Skin is intact, no reddened areas. Skin is smooth
and even and without lesions. Skin is appropriately hydrated. Skin is cool in temperature.

Nails are clean and well-groomed. Nails are pink in color, hard and immobile. Positive capillary refill within one second. No
lesions or masses noted.

Radial pulses are strong bilaterally at 2+.

CN XI intact. Muscles are fully developed and symmetric. All muscle groups equally strong against resistance. No
fasciculations, tics or tremors noted. No edema noted. RAM intact.

Abdomen/Genitalia (Bowel sounds, distention, tenderness, masses, appetite, dietary patterns, GI & GU elimination,
menstrual/sexual/reproductive patterns as applicable etc.)

Skin tone normal and even. Large dark circular birthmark noted mid-abdomen; 10cm in width, 22cm in length. Stomach is
shaved free of hair. Colostomy bag present on LLQ. Colostomy drainage minimal, liquid. Stoma is beefy red in appearance.
No lesions or rashes noted. Umbilicus is midline, inverted and symmetrical. Abdomen is protuberant and symmetrical. No
aortic pulsation observed. No peristaltic waves noted. Hypoactive bowel sounded noted in RUQ, RLQ, LUQ, LLQ. No bruit
noted over abdominal aorta, renal or iliac arteries. No venous hum noted. No friction rub noted. Dullness noted over the
liver. Tympany noted over the abdomen. Liver and spleen unable to be percussed or palpated. Abdomen is tender and soft.
No masses present. Aorta unable to be palpated. Abdomen is positive for pain upon light palpation.

No GI/GU abnormalities stated. No hunger stated.

Back (spinal curvature, skin, etc.)

Unable to be assessed d/t immobility and pain.

Lower Extremities (pulses, ROM, ambulatory status, strength, capillary refill, Homans sign, mobility, etc.)

Hair covers skin of the legs. Legs are free of lesions or ulcerations. Identical size and shape bilaterally. No swelling or
atrophy. No edema noted. Legs, feet and toes are equally cool bilaterally. Popliteal pulses difficult to detect bilaterally.
Dorsalis pedis pulses bilaterally strong, 2+. Veins are flat and unnoticeable under the skin. Evenly colored skin tone
without unusual discolorations. No odor noted. Skin is intact, no reddened areas. Skin is smooth and even and without
lesions. Skin is appropriately hydrated. Skin is cool in temperature. Legs unable to be straightened.

Nails are clean and well-groomed. Nails are pink in color, hard and immobile. Positive capillary refill within one second. No
lesions or masses noted.

Muscles are fully developed and symmetric. All muscle groups equally strong against resistance. No fasciculations, tics or
tremors noted. RAM intact. Immobility present.

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Sleep Patterns

Normal: PT states he sleeps eight hours. PT states he does not have difficulty falling asleep or waking up. PT states he
sometimes wakes in the middle of the night, but does not have difficulty falling back asleep. PT states he has sleep
apnea, but has not been using his machine because the mask broke after the tubing snapped.

Present: PT states he sleeps for approximately two hours, wakes for 1-1.5 hours and then falls back asleep. PT states his
sleep is not productive. PT states he is not currently using a sleep apnea machine. PT states he has trouble falling
asleep because of the pain. PT states he sometimes has trouble falling back asleep when he awakes and has not had
any pain medication.

Pain Assessment (5 parameters must be included)

PT states his pain is a 7 out of 10. PT states his pain is in LLQ and began after his surgery and is still present. PT identifies
the pain as stabbing. PT states that pain medication helps to alleviate the pain and moving aggravates the pain. PT
states he has a radiating pain that travels from LLQ to his back and is shooting. PT states that the best treatment for
his pain is his pain medication.

Special Considerations:

PT currently has one IV line in his R arm. PT currently has a catheter in his colostomy to alleviate gas. PT states the
colostomy will be in place for approximately 2 months. PT states the colostomy will have no impact on his person life.
PT denies concern of having a colostomy. PT believes he can adequately take care of his colostomy. PT prefers his
arms up, his sheet tucked in and to not wear a gown. PT states his father and he are close, that his father came to visit
twice and that his father is on disability for his back.

Update: No changes noted in the previous days assessment.

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1. Describe the Level of Growth and Development. 2. How does this patient compare to norms? 3. Which end of the
spectrum is the patient in? Give evidence to support your statement.

PT is in the Intimacy vs Isolation stage of growth and development. This stage covers young adulthood from the ages
of late teens to mid 30s. At this stage, physical growth is completed. There is a focus on personal and social tasks
including career choices, social and intimate relationships, self-concepts, and adult relationships with family. Heath
concerns include accidents, violence, STDs, job and family stress, unhealthy lifestyle practices. The importance of this
stage is for young adults to form intimate, loving relationships with other people. If a person is successful at this, they
will have strong relationships, but if they do not, they will have loneliness and isolation. PT is in the beginning stages of
this development. He is able to build strong relationships and has identified a career path, but has not made steps
toward attaining his goal. PT has identified his sexuality, but is single and is not open with his sexual preferences. PT is
a role model for his younger brothers and has strong friendships, but has not built strong intimate relationships.

List All Patient Problems (Weaknesses):

PT does not take criticism well. PT states that he is often told he is not reaching his fullest potential. PT is often told this by
his step-mother when she is mad he is playing video games. PT desires a career in video editing, but has not started
school. PT is unemployed and unable to provide for his family. PT is of low socioeconomical status. PT most likely has poor
sexual education which resulted in his admittance to the hospital. PT knows his sexual preference, but has not
communicated his preference to his family. PT current is immobile. PT has poor dietary habits and is obese. PT currently
has a colostomy and carries the associated risks. PT does not use a sleep apnea machine even though he understands his
diagnosis.

List Patient Strengths:

1. Physical PT states he is a good problem solver and is handy. PT states he has above average dexterity. PT believes he
is funny and likes telling jokes. PT states he is good at finding the positive in things.
PT is able to perform above average RAM. PT is able to reach call bell despite immobility. PT is an independent
feeder. PT is able to use a bedside urinal without assistance. PT displays adequate knowledge of colostomy care.

2. Psychological PT states he has a good memory and is good at history. PT states he is like Dr. Phil to his friends and is
able to help them through problems they are experiencing. PT states he is able to self-heal any mental blocks. PT states he
was bullied in 5th and 6th grades, but overcame it by ignoring the bullies. PT has a strong group of friendships he is able to
maintain, but has engaged in illicit activities like stealing street signs.
PT is able to communicate. PT is able to discuss sexuality and family dynamics without noticeable discomfort. PT
exhibits positive self-esteem and positive body image with colostomy care. PT demonstrates appropriate relationships and
interest in social interaction.

3. Socio-cultural PT states he enjoys helping his brothers. PT states he is a big help to his friends. PT states he easily
acclimates and associates to the Puerto Rican culture.
PT expresses comfort in seeking assistance from family and friends. PT is able to live with two brothers in one
bedroom without conflict. PT expresses strong social identify. PT exhibits nondiscriminatory behaviors.

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Medical and/or Surgical Treatment: (Any special diagnostic measures or treatment not done by nursing personnel)

2016 Colostomy
2001 bilateral ACL repair d/t congenital defects

Diet Therapy
Name of Diet: Soft

Types of Food (List 2 acceptable foods from the following food groups)
Bread/Cereal: Moist dry or cooked cereal; macaroni noodles
Fruit/Vegetable: Applesauce; soft, well-cooked vegetables
Milk: ice cream; yogurt
Meat: cooked eggs; soup with small, soft pieces of meat

Purpose of this diet and relation to the current diagnosis and/or other medical problems?

Soft foods are gentle on the stomach and more easy to digest. Soft foods may help to alleviate discomfort and negative side
effects as the bowel learns a new digestion process. Additionally, a soft food diet can help to alleviate gas or obstruction
caused from improper food choices.

PT has a newly placed colostomy and was experiencing gas, resulting in the placement of a catheter within the colostomy. A
soft food diet would help his body to adjust at a conservative rate and decrease complications.

X-Rays:

Date & Procedure Pertinent Findings:

15 November 2016 3-way abdomen/chest X-ray Foreign Body; radiopaque cylindrical structure within the
distal sigmoid colon approximately 18cm x 5cm.

No evidence of bowel obstruction. No evidence of free air.

Lungs clear, no free air under the diaphragm, normal

visceral outlines.

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 Laboratory Tests: If there are multiple tests of the same lab, do the first one and the most recent one.
Name of Test Date Patient Values Normal Values Significance
Relating to

Hematology

WBC 18 Nov 16 23,100/uL 4,500-12,500/uL Increased WBC d/t surgery

RBC 18 Nov 16 6,970,000/uL 4,700,000-6,100,00/uL Increased RBC d/t surgery
Hgb 18 Nov 16 17.8 g/dL 13.5-18 g/dL WNL; tests ability of RBC to carry oxygen
Hct 18 Nov 16 51.3% 41-54% WNL; percentage of RBC in blood
MCV 18 Nov 16 73.6 fL 80-95 fL Low MCV; possible anemia
MCH 18 Nov 16 25.5 pg 27-31 pg Low MCH; possible anemia
MCHC 18 Nov 16 34.7 g/dL 31-36 g/dL WNL; average concentration of hemoglobin
Plts 18 Nov 16 229,000/uL 150,000-450,000/uL WNL; helps to control bleeding
RDWSD 18 Nov 16 37.9 fL 35.1-43.9 fL WNL; indicates size of RBC
RDWCV 18 Nov 16 14.5% 11.6-14.4% High RDWCV; possible anemia
MPV 18 Nov 16 11.4 fL 7.4-10.4 fL High MPV; large platelets
NRBC 18 Nov 16 0% % WNL; nucleated RBC, only in fetus/infants
NRBCAB 18 Nov 16 0/uL 0-10/uL WNL; nucleated RBC, only in fetus/infants

Chemistry

Sodium 18 Nov 16 135 mmol/L 136-145 mmol/L Low Sodium; can cause damage to cells
Potassium 18 Nov 16 3.8 mmol/L 3.5-5.1 mmol/L WNL; aids in nerve/muscle communication
Chloride 18 Nov 16 98 mmol/L 98-107 mmol/L WNL; maintains cellular fluid balance
CO2 18 Nov 16 24 mmol/L 21-32 mmol/L WNL; maintains pH of blood
BUN 18 Nov 16 17 mg/dL 7-18 mg/dL WNL; monitors kidney function
Creatinine 18 Nov 16 1.40 mg/dL 0.55-1.3 mg/dL High Creatinine; impaired kidney function
Glucose 18 Nov 16 113 mg/dL 74-106 mg/dL High glucose; can indicate diabetes
Calcium 18 Nov 16 9.5 mg/dL 8.5-10.1 mg/dL WNL; excretion of calcium from body
GFR 18 Nov 16 >60 mls/min/1.73m2 >60 mls/min/1.73m2 WNL; estimates kidney function

Coagulation

INR 18 Nov 16 1.0 0.8-1.2 sec WNL; assesses time for blood to clot
PT 18 Nov 16 10.8 9.7-12.4 sec WNL; assesses clotting or anticoagulants
PTT 18 Nov 16 25.6 24.3-34.6 sec WNL; aids in assessing bleeding problems

Drug Therapy: Dosage, Is dose

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 Drug Ordered Time Interval & appropriate Side Effects Action of drug Reason for use in
(Generic & Trade) Method of for your *List 2 from this patient
& Classification Administration patient? each system

cefazolin D5W 2g/50mL IV for 10 days; yes; max dose Neutropenia; Bactericidal; Broad spectrum
(Duplex) infuse over 30 minutes is 3000 mg Stevens- inhibits cell antibiotic for
Ancef Johnson wall synthesis surgery d/t elevated
Cephalosporin,1st Gen syndrome WBC

enoxaparin sodium 40 mg = 0.4 mL yes; max dose Skin necrosis; Inhibits anticoagulant to
Lovenox SQ Q24hr for 14 days is 202.95 mg Hyperkalemia thrombin and prevent DVT
Anticoagulant factor Xa

influenza vaccine 0.5 mL IM once yearly yes; no weight Guillian-Barre; Induces Prevent flu
Fluarix based dosing Vasculitis antibody contamination
Influenza Vaccine formation

metronidazole 500mg/100mL IV Q8hr yes; 500mg Q6- Leukopenia; Bactericidal; To decrease WBC
Flagyl preop then 2 doses 8hr Seizures inhibits
Antiparasitics nucleic acid
synthesis

lactated ringers/NJ 1,000mL IV at 100mL/hr yes; no weight Hypervolemia; Controls Increase fluid and
Ringer-Lactate over 10hr for 30 days based dosing Venous electrolyte electrolytes
Electrolytes thrombosis balance

pantoprazole sodium 40mg/10mL IV daily for yes; max dose Rhinitis, UTI Inhibits proton PPI for acid reflux
Protonix 30 days is 120 mg pump to
Antiulcer-PPI suppress
gastric acid

pneumococcal 23-val 0.5mL IM yes; no weight Fainting; vision Induces prevention of

P-sac vac based dosing changes antibody pneumonia
Pneumovax 23 formation
Pneumonia Vaccine

hydraAlazine 5 mg = 0.25 mL yes; max dose MI; Peripheral Dilates Decrease HR

Apresoline IV Q6hr PRN for 30 is 40 mg neuritis peripheral if SBP > 160mmHg
Anti-hypertensive days vessels

hydromorphone 1 mg = 0.5 mL IV Q3hr yes; max dose Respiratory Binds to pain management
Dilaudid PRN is 1 mg/mL depression; opioid
Opioid Analgesic paralytic ileus receptors

morphine sulfate 2 mg = 1 mL yes; max dose Apnea; biliary Binds to pain management
Duramorph IV Q1hr PRN for 14 is 20 mg spasm opioid
Opiod Analgesic days receptors

ondansetron HCl 4 mg = 2 mL IV Q6hr yes; max dose Extrapyramidal Antagonizes nausea d/t pain or
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 Zofran PRN over 2-5 mins is 4 mg/2 mL Bronchospasm serotonin 5- medication therapy
Antiemetic HT3 receptors

oxycodone 1-2 10 mg tab PO Q4hr yes; max dose Bradycardia; Binds to pain management
HCl/acetaminophen PRN for 14 days is 80 mg respiratory opioid
Percocet 1 tab for pain 4-6/10 depression receptors
Opioid Analgesic 2 tab for pain 7-10/10

sodium chloride 0.9% 0.4 mg = 1 mL IV yes; max dose Seizures; Antagonizes itching d/t neuraxial
(500 mL bag) at 30 mL/hr over 16.75 is 2 mg ventricular opioid opioid injection
Naloxone hr PRN itching fibrillation receptors
Opioid Antagonist immediately then
routine for 2 days

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Collaborative Problems

Potential Complications Nursing Measures

Medical Dx: Colostomy

Collaborative Problems:
Risk for Complications of Peristomal Tissue
Risk for Complications of Stoma
Risk for Complications of Intra-abdominal sepsis
Risk for Complications of Large Bowel Obstruction
Risk for Complications of Perforation of Genitourinary Tract

Collaborative Outcomes:
The client will be monitored for early signs and symptoms of:
a) peristomal complications
b) stomal complications
c) intra-abdominal sepsis
d) large bowel obstruction
e) perforation of genitourinary tract
The client will receive collaborative interventions if indicated to restore physiologic stability.

Nursing Interventions
1. Monitor for stomal complications:
a. Parastomal hernia defect in the abdominal fascia allowing the gut to bulge into the parastomal area
b. Prolapsed (telescoping of the bowel through the stoma)
c. Necrosis (death of stomal tissue with impaired local blood flow)
d. Mucocutaneous separation, retraction, (disappearance of normal stomal protrusion in line with or below
skin level)
e. Stenosis, fistula, trauma
2. Monitor for peristomal complications:
a. Varices
b. Candidiasis, folliculitis, necrosis
c. Trauma
3. Monitor the peristomal area for the following:
a. Decreased peristomal muscle tone
b. Bulging beyond the normal skin surface and musculature
c. Persistent ulceration
4. Monitor the following:
a. Color, size, and shape of the stoma; and mucocutaneous separation
b. Color, amount, and consistency of ostomy effluent
c. Complaints of cramping abdominal pain, nausea and vomiting, and abdominal distention
d. Fit of ostomy appliance and appliance belt
5. If mucocutaneous separation occurs, notify wound/ostomy nurse specialist or surgeon,
6. Monitor perineal wound for signs and symptoms of infection, bleeding, drainage
7. Monitor for intra-abdominal sepsis:
a. Complaints of nausea, hiccups
b. Spiking fevers, chills
c. Tachycardia
d. Elevated WBC
8. Monitor for intestinal obstruction
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 a. Increasing pain
b. Decreased/absent bowel sounds or hyperperistalsis
c. Clinical evidence of hypovolemia
9. Monitor for large bowel obstruction; notify the physician/NP, if detected:
a. Decreased bowel sounds
b. Nausea, vomiting
c. Abdominal distension
10. Monitor for perforation of the bladder:
a. Acute pelvic pain
b. Nausea, vomiting, malaise
c. Abdominal distension
d. Costovertebral angle tenderness, ileus, fever, flank pain
11. Notify surgeon for radiographic evaluation.

Rationales
1. The most common complications were stomal retraction, peristomal hernia, prolapse, necrosis, and
peristomal skin problems (Carpenito, 2014).
2. Complications affect the skin immediately surrounding the stoma (Colwell & Beitz, 2007).
3. Early detection of ulcerations and herniation can prevent serious tissue damage (Carpenito, 2014).
4.
a) These changes can indicate inflammation, retraction, prolapse, or edema (Carpenito, 2014).
b) These complaints can indicate bleeding or infection. Decreased output can indicated obstruction
(Carpenito, 2014).
c) These complaints may indicate obstruction (Carpenito, 2014).
d) An improperly fitting appliance or belt can cause mechanical trauma to the stoma (Colwell & Beitz,
2007).
5. Special Techniques are needed to prevent fecal contamination.
6. Tissue responds to pathogen infiltration with increased blood and lymph flow (manifested by edema,
redness, and increased drainage) and reduced epithelialization (marked by wound separation). Circulating
pathogens trigger the hypothalamus to elevate the body temperature; certain pathogens cannot survive at
higher temperatures (Carpenito, 2014).
7. Intraoperative manipulations of abdominal organs and the depressive effects of narcotics and anesthesia
on peristalsis can cause paralytic ileus, typically developing between the third and fifth postoperative day
(Carpenito, 2014).
a) Hiccups may be related to phrenic nerve irritation resulting from subdiaphragmatic collection of purulent
debris (Carpenito, 2014).
b) Endogenous pyrogens are released and reset the hypothalamic set points in febrile levels. The body
temperature is sensed as too cool; shivering and vasoconstriction result to generate and consume
heat. Core temperature rises to the new level of the set point, resulting in fever (Carpenito, 2014).
c) Decreased blood flow to the brain, heart, and kidneys triggers baroreceptors and release of
catecholamines, increasing heart rate/cardiac output and further increasing vasoconstriction.
d) Increased white blood cells indicate an infectious process.
8. Intestinal obstruction is also common. Stoma strictures can occur at the skin level, fascial level, or both.
Partial obstruction can result in hyperperistalsis and hypersecretion; massive fluid loses through the stoma
may result in dehydration. Other causes of obstruction include luminal plugging caused by ingested food,
adhesive intestinal obstruction, internal hernia, and volvulus (Minkes, 2013).
9. Intraoperative manipulation of the abdominal organs and the depressive effects of anesthesia and narcotics
can decrease peristalsis (Carpenito, 2014).
10. Intraoperatively, the bladder can be punctured during the colon resection. Urine leakage into the perineum
will cause infection.
11. Radiographic confirmation is the only valid confirmation of internal complications (Carpenito, 2014).

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Related Physician/NP Prescribed Interventions
Medications: Antibiotics (e.g., kanamycin, erythromycin, neomycin); chemotherapy; immunotherapy; laxatives
(preoperative)
Laboratory Studies: Carcinoembryonic antigen (CEA)
Diagnostic Studies: Flat plate of abdomen, computed tomography (CT) scan of abdomen
Therapies: Radiation therapy (preoperative, intraoperative, postoperative)

Medical Dx: Hypertension

Collaborative Problems
Risk for Complications of Vascular Insufficiency

Collaborative Outcomes:
The client will be monitored for early signs and symptoms of vascular insufficiency and will receive collaborative
interventions if indicated to restore physiological stability AEB no new visual defects, orientated, equal strength
upper/lower extremities.

Nursing Interventions
1. Monitor for evidence of tissue ischemia.
a) Visual defects including blurring, spots, and loss of visual acuity
b) Cerebrovascular deficits
Orientation or memory deficits
Weakness
Paralysis
Mobility, speech, or sensory deficits
c) In addition to extreme readings, a person in hypertensive crisis may experience:
Severe headaches (brain swelling and dysfunction)
Severe anxiety (brain swelling and dysfunction)
Lightheadedness, vertigo (brain swelling and dysfunction)
Nosebleeds (rupture of a blood vessel within the richly perfused nasal mucosa)
d) Renal insufficiency
Decreased serum protein level
Sustained elevated urine specific gravity
Elevated urine sodium levels
Increased BUN, serum potassium, creatinine, potassium, phosphorus, and ammonia levels; decreased
creatinine clearance
Sustained insufficient urine output (<0.5 mL/kg/h)
e) Cardiac insufficiency

Rationales
1. Hypertension adversely affects the entire cardiovascular system. Chronic increases in perfusion pressure
results in hypertrophy of vascular smooth muscle and increased collagen concentration. These changes reduce
the lumen size of the blood vessels, change the vessels shape, and gives rise to cyclospasm of the vessel
cells. The results are plaque formation from increased adherence of monocytes to the endothelium. The
increase in the wall-to-lumen ratio in the arteries causes greater vessel resistance and a reduced ability to
dilate in response to increased metabolic need for oxygen (Porth, 2011).
a. Evidence of blood vessel damage in the retina indicates similar damage elsewhere in the vascular
system (Carpenito, 2014).

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 b. In the brain, sustained hypertension causes progressive cerebral arteriosclerosis and ischemia.
Interruption of cerebral blood supply caused by cerebral artery occlusion or rupture results in sensory
and motor deficits (Carpenito, 2014).
c. Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic 110-sometimes
termed malignant or accelerated hypertension) is referred to as a hypertensive crisis, as blood
pressures above these levels are known to confer a risk of complications, e.g. (left ventricular failure,
actue renal injury) (Carpenito, 2014).
d. With decreased blood supply to the nephrons, the kidney loses some ability to concentrate and form
normal urine (Porth, 2011).
Further structural abnormalities may cause the vessels to become more permeable and
allow leakage of protein into the renal tubules (Carpenito, 2014).
Decreased ability of the renal tubules to reabsorb electrolytes causes increased urine
sodium levels and increased specific gravity (Carpenito, 2014).
Decreased renal function impairs the excretion of urea and creatinine in the urine, thus
elevating BUN and creatinine levels (Carpenito, 2014).
Decreased glomerular filtration rate eventually causes insufficient urine output and
stimulates renin production, which results in increase blood pressure in attempt to increase
blood flow to the kidneys (Carpenito, 2014).
e. Microvascular coronary atherosclerotic plaques or vasospasm reduce the caliber of vessel and its
ability to oxygenate tissue (Porth, 2011).

Related Physician/NP Prescribed Interventions

Medications: Diuretics, beta-blockers, ace inhibitors, angiotensin II receptor blockers, alpha blockers, alpha-z
receptor agonist, combined alpha and beta-blockers, central agonists, peripheral adrenergic inhibitors, and
blood vessel dilators or vasodilators (these are classes of blood pressure drugs). Diuretics enhance the
antihypertensive efficacy of multi-drug regimens, can be useful in achieving BP control, and are more
affordable than other antihypertensive agents.
Intravenous Therapy: Not indicated.
Laboratory Studies: Hemoglobin/hematocrit, serum cholesterol, triglycerides; thyroid studies; urinalysis,
BUN/creatinine clearance; 24-hour urine for vanillylmandelic acid (VMA), catecholamine; aldosterone
(serum, urine); uric acid; serum glucose/fasting; urine steroids; serum potassium, calcium. Routine
laboratory tests recommended before initiating therapy include an electrocardiogram; urinalysis; blood
glucose and hematocrit; serum potassium, creatinine (or the corresponding estimated glomerular filtration
rate [GFR]), and calcium; and a lipid profile, after 9- to 12-hour fast, that includes high-density lipoprotein
cholesterol and low-density lipoprotein cholesterol, and triglycerides. Optional tests include measurement of

urinary albumin excretion or albumin/creatinine ratio.

Diagnostic Studies: ECG, chest c-ray, renal scan
Therapies: Sodium-restricted diet, decreased fat diet and exercise

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Complete List of Nursing Diagnoses in Complete and Correct Format and prioritized (include those diagnoses for which you
are completing in your NCP)

Risk for Complications of Stoma r/t surgery AEB exposed stoma

Goal: Patient will maintain a clean, infection-free environment for his stoma by the end of my shift.
Evaluation: Goal was met; patients stoma is beefy red in color, colostomy bag was clean, and patient stated he felt
comfortable caring for his colostomy.
Imbalanced Nutrition: More Than Body Requirements r/t being overweight AEB BMI of 40.31 kg/m 2
Goal: Patient will eat a lunch that meets his dietary requirements and fulfills providers prescribed diet therapy.
Evaluation: Goal was partially met; patient is following his prescribed diet therapy, but reported that he was not
hungry and did not eat any of his lunch.
Risk for Disturbed Self-Concept r/t effects of ostomy on body image and lifestyle AEB colostomy bag
Goal: Patient will report knowledge on care of colostomy and discuss any concerns he has regarding the impacts
the colostomy will have on his life in order to alleviate any anxiety or stress by the end of the shift.
Evaluation: Goal was met; patient stated the colostomy will have no impact on his person life, he denied concern of
having a colostomy, and stated that he believes he can adequately take care of his colostomy.

Source Used in Preparation:

Patient chart

Patient

Head-to-toe physical Assessment

Nursing Care Plans book

Internet sources

Nursing 2017 Drug Handbook

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