Outcomes (NOC)	Interventions (NIC) and Rationales
Bowel Elimination • Diarrhea _____ • Mucus in stool ____ • Blood in stool ____ • Pain with passage of stool _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Diarrhea Management • Obtain stool for culture and sensitivity if diarrhea continues to identify etiology and provide appropriate treatment. • Perform actions to rest bowel (e.g., NPO, liquid diet). • Instruct patient to notify staff of each episode of diarrhea to monitor effectiveness of treatment. • Instruct patient/family members to record color, volume, frequency, and consistency of stools to monitor treatment. • Teach patient appropriate use of antidiarrheal medication to prevent patient’s use of OTC antiperistaltic agents that prolong exposure to infectious organism Infection Control • Place on designated isolation precautions to prevent spread of infection. • Wash hands before and after each patient care activity to prevent spread of infection. • Wear gloves as mandated by universal precaution policy to prevent infection transmission. • Wear scrub clothes or gown when handling infectious material to avoid contaminating self and others.

Outcomes (NOC)

Interventions (NIC) and Rationales

Bowel Elimination

• Diarrhea _____

• Mucus in stool ____

• Blood in stool ____

• Pain with passage of stool _____

• Obtain stool for culture and sensitivity if diarrhea continues to identify etiology and provide appropriate treatment.

• Perform actions to rest bowel (e.g., NPO, liquid diet).

• Instruct patient to notify staff of each episode of diarrhea to monitor effectiveness of treatment.

• Instruct patient/family members to record color, volume, frequency, and consistency of stools to monitor treatment.

• Teach patient appropriate use of antidiarrheal medication to prevent patient’s use of OTC antiperistaltic agents that prolong exposure to infectious organism

Infection Control

• Place on designated isolation precautions to prevent spread of infection.

• Wash hands before and after each patient care activity to prevent spread of infection.

• Wear gloves as mandated by universal precaution policy to prevent infection transmission.

• Wear scrub clothes or gown when handling infectious material to avoid contaminating self and others.

Nursing Diagnosis

Deficient fluid volume related to excessive fluid loss and decreased fluid intake secondary to diarrhea as evidenced by dry skin and mucous membranes, poor skin turgor, orthostatic hypotension, tachycardia, decreased urine output, and/or electrolyte imbalance

Patient Goals

1. Maintains fluid and electrolyte balance

2. Demonstrates no hypovolemia or hypervolemia

Outcomes (NOC)	Interventions (NIC) and Rationales
Fluid Balance • Blood pressure _____ • Radial pulse rate _____ • Stable body weight _____ • 24-hour intake and output balance _____ • Moist mucous membranes _____ • Serum electrolytes _____ • Skin turgor _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Hypovolemia Management • Observe for indications of dehydration (e.g., poor skin turgor, delayed capillary refill, weak/thready pulse, severe thirst, dry mucous membranes, decreased urine output, and hypotension) to evaluate fluid status. • Monitor fluid status, including intake and output, to determine fluid balance. • Monitor vital signs to detect hypovolemia. • Monitor weight to monitor fluid loss. • Encourage oral fluid intake if intake does not stimulate intestinal hypermotility. • Maintain a steady IV infusion flow rate to replace fluids and electrolytes lost in stools. Fluid/Electrolyte Management • Administer prescribed supplemental electrolytes to replace electrolytes lost in stools. • Monitor laboratory results relevant to fluid balance (e.g., hematocrit, BUN, albumin, total protein, serum osmolality, and urine specific gravity levels).

Outcomes (NOC)

Interventions (NIC) and Rationales

Fluid Balance

• Blood pressure _____

• Radial pulse rate _____

• Stable body weight _____

• 24-hour intake and output balance _____

• Moist mucous membranes _____

• Serum electrolytes _____

• Skin turgor _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Hypovolemia Management

• Observe for indications of dehydration (e.g., poor skin turgor, delayed capillary refill, weak/thready pulse, severe thirst, dry mucous membranes, decreased urine output, and hypotension) to evaluate fluid status.

• Monitor fluid status, including intake and output, to determine fluid balance.

• Monitor vital signs to detect hypovolemia.

• Monitor weight to monitor fluid loss.

• Encourage oral fluid intake if intake does not stimulate intestinal hypermotility.

• Maintain a steady IV infusion flow rate to replace fluids and electrolytes lost in stools.

Fluid/Electrolyte Management

• Administer prescribed supplemental electrolytes to replace electrolytes lost in stools.

• Monitor laboratory results relevant to fluid balance (e.g., hematocrit, BUN, albumin, total protein, serum osmolality, and urine specific gravity levels).

Nursing Diagnosis

Risk for impaired skin integrity related to perianal exposure to chemical irritants and excretions

Patient Goal

Maintains intact, healthy perineal tissue

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes • Erythema _____ • Skin lesions _____ • Induration _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Perineal Care • Clean the perineum thoroughly at regular intervals to remove irritants and excretions. • Keep the perineum dry to prevent excoriation from moisture. • Provide sitz baths to clean perineum and promote blood flow to area. Skin Surveillance • Inspect skin and mucous membranes for redness, extreme warmth, edema, or drainage to provide early intervention. • Document skin or mucous membrane changes to evaluate effect of interventions.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous Membranes

• Clean the perineum thoroughly at regular intervals to remove irritants and excretions.

• Keep the perineum dry to prevent excoriation from moisture.

• Provide sitz baths to clean perineum and promote blood flow to area.

Skin Surveillance

• Inspect skin and mucous membranes for redness, extreme warmth, edema, or drainage to provide early intervention.

• Document skin or mucous membrane changes to evaluate effect of interventions.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 43-2 Patient With Inflammatory Bowel Disease

Nursing Diagnosis*

Patient Goals

1. Experiences a decrease in the number of diarrhea stools

2. Stools are soft and formed

Outcomes (NOC)	Interventions (NIC) and Rationales
Bowel Elimination • Elimination pattern _____ • Ease of stool passage _____ • Stool soft and formed _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Diarrhea Management • Instruct patient/caregiver to record color, volume, frequency, and consistency of stools to evaluate effectiveness of therapy and dietary restrictions. • Perform actions to rest the bowel (e.g., NPO, liquid diet). • Teach patient stress-reduction techniques to reduce the incidence of exacerbations. • Encourage frequent, small feedings, adding bulk gradually, to prevent bowel irritation. • Teach patient/caregiver to eliminate gas-forming and spicy foods from diet to decrease inflammation. • Instruct in low-fiber, high-protein, high-calorie diet to meet nutritional needs with minimum bowel irritation.

Outcomes (NOC)

Interventions (NIC) and Rationales

Bowel Elimination

• Elimination pattern _____

• Ease of stool passage _____

• Stool soft and formed _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Diarrhea Management

• Instruct patient/caregiver to record color, volume, frequency, and consistency of stools to evaluate effectiveness of therapy and dietary restrictions.

• Perform actions to rest the bowel (e.g., NPO, liquid diet).

• Teach patient stress-reduction techniques to reduce the incidence of exacerbations.

• Encourage frequent, small feedings, adding bulk gradually, to prevent bowel irritation.

• Teach patient/caregiver to eliminate gas-forming and spicy foods from diet to decrease inflammation.

• Instruct in low-fiber, high-protein, high-calorie diet to meet nutritional needs with minimum bowel irritation.

Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to decreased intake, decreased absorption, and increased nutrient loss through diarrhea as evidenced by anorexia, weight loss, weakness, lethargy and/or anemia

Patient Goals

1. Consumes calories and nutrients adequate to meet nutritional needs

2. Maintains body weight within a normal range

3. Demonstrates increased muscle tone and strength

Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status • Nutrient intake _____ • Food intake _____ • Fluid intake _____ • Weight/height ratio _____ • Hematocrit _____ • Energy _____ • Muscle tone _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	Nutritional Monitoring • Weigh patient at specified intervals to evaluate nutritional status and response to treatment. • Monitor albumin, total protein, hemoglobin, and hematocrit levels to determine nutritional status. • Monitor energy level, malaise, fatigue, and weakness as signs of inadequate nutrition. Nutrition Therapy • Monitor food/fluid ingested and calculate daily caloric intake to determine adequacy of caloric intake. • Administer parenteral nutrition as appropriate to maintain nutrition while resting the bowel. • Select nutritional supplements to provide additional calories, iron, protein, and fluid. • Instruct patient/caregiver about prescribed diet that will maintain nutrition without irritation of the bowel. • Refer for diet teaching and planning as needed.

Outcomes (NOC)

Interventions (NIC) and Rationales

Nutritional Status

• Nutrient intake _____

• Food intake _____

• Fluid intake _____

• Weight/height ratio _____

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Nutritional Monitoring

• Weigh patient at specified intervals to evaluate nutritional status and response to treatment.

• Monitor albumin, total protein, hemoglobin, and hematocrit levels to determine nutritional status.

• Monitor energy level, malaise, fatigue, and weakness as signs of inadequate nutrition.

Nutrition Therapy

• Monitor food/fluid ingested and calculate daily caloric intake to determine adequacy of caloric intake.

• Administer parenteral nutrition as appropriate to maintain nutrition while resting the bowel.

• Select nutritional supplements to provide additional calories, iron, protein, and fluid.

• Instruct patient/caregiver about prescribed diet that will maintain nutrition without irritation of the bowel.

• Refer for diet teaching and planning as needed.

Nursing Diagnosis

Chronic pain related to chronic intestinal inflammatory process as evidenced by fatigue, facial mask (e.g., eyes lack luster, beaten look, fixed or scattered movement, grimace), irritability, and/or observed protective behavior

Patient Goals

1. Reports free from pain and discomfort

2. Demonstrates reduction of disruptive effects of pain

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain: Disruptive Effects • Disruption of interpersonal relationships _____ • Impaired concentration _____ • Impaired mood _____ • Interrupted sleep _____ • Impaired role performance _____ • Difficulty maintaining employment _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Pain Management • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to establish baseline pain experience. • Determine the impact of the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, performance of job, and role responsibilities) to plan appropriate interventions. • Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient’s response to pain. • Select and implement a variety of measures (e.g., pharmacologic, nonpharmacologic, interpersonal) to facilitate pain relief. • Notify physician if measures are unsuccessful or if current complaint is a significant change from patient’s past experience of pain to detect worsening of condition. • Consider referrals for patient, family, and significant others to support groups and other resources to promote pain management.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain: Disruptive Effects

• Disruption of interpersonal relationships _____

• Impaired concentration _____

• Impaired mood _____

• Interrupted sleep _____

• Impaired role performance _____

• Difficulty maintaining employment _____

• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to establish baseline pain experience.

• Determine the impact of the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, performance of job, and role responsibilities) to plan appropriate interventions.

• Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient’s response to pain.

• Select and implement a variety of measures (e.g., pharmacologic, nonpharmacologic, interpersonal) to facilitate pain relief.

• Notify physician if measures are unsuccessful or if current complaint is a significant change from patient’s past experience of pain to detect worsening of condition.

• Consider referrals for patient, family, and significant others to support groups and other resources to promote pain management.

Nursing Diagnosis

Ineffective coping related to chronic disease, lifestyle changes, inadequate level of confidence in ability to cope, and inadequate opportunity to prepare for stressor as evidenced by inability to express feelings and concerns, lack of goal-directed behavior, and verbalization of inability to cope

Patient Goals

1. Demonstrates the use of effective coping strategies

2. Expresses a sense of self-control and reduced stress

Outcomes (NOC)	Interventions (NIC) and Rationales
Coping • Identifies ineffective coping patterns _____ • Identifies multiple coping strategies _____ • Uses effective coping strategies _____ • Verbalizes sense of control _____ • Verbalizes acceptance of situation _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Coping Enhancement • Confront patient’s anxiety and/or depression to identify ineffective coping patterns. • Foster constructive outlets for anger and hostility as a therapeutic measure. • Encourage verbalization of feelings, perceptions, and fears to evaluate coping strategies. • Assist the patient in identifying appropriate short- and long-term goals. • Assist the patient to identify available support systems. • Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes. • Assist the patient to grieve and work through the losses of chronic illness. • Encourage patient to evaluate own behavior to assist patient in recognizing effective and ineffective behaviors.

Outcomes (NOC)

Interventions (NIC) and Rationales

Coping

• Identifies ineffective coping patterns _____

• Identifies multiple coping strategies _____

• Uses effective coping strategies _____

• Verbalizes sense of control _____

• Verbalizes acceptance of situation _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Coping Enhancement

• Confront patient’s anxiety and/or depression to identify ineffective coping patterns.

• Foster constructive outlets for anger and hostility as a therapeutic measure.

• Encourage verbalization of feelings, perceptions, and fears to evaluate coping strategies.

• Assist the patient in identifying appropriate short- and long-term goals.

• Assist the patient to identify available support systems.

• Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes.

• Assist the patient to grieve and work through the losses of chronic illness.

• Encourage patient to evaluate own behavior to assist patient in recognizing effective and ineffective behaviors.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge of course of disease, appropriate lifestyle adjustments, and nutritional and drug therapy as evidenced by questioning about the disease and treatment, poor decisions about activities of daily living

Patient Goals

1. Describes the disease process and treatment regimen

2. Expresses confidence in ability to care for self with regard to medication administration and diet therapy

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Treatment Regimen • Specific disease process _____ • Rationale for treatment _____ • Self-care responsibilities for ongoing treatment _____ • Prescribed medication regimen _____ • Prescribed diet _____ • Benefits of disease management _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Disease Process • Appraise the patient’s current level of knowledge related to specific disease process to establish knowledge basis for teaching. • Describe disease process to ensure patient has adequate knowledge about the diseases and treatment. • Describe the rationale behind management/therapy/treatment recommendations to enhance compliance with treatment. • Reinforce information provided by other health care professionals. • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process. • Instruct the patient on which signs and symptoms to report to health care provider to prevent complications.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Treatment Regimen

• Specific disease process _____

• Rationale for treatment _____

• Self-care responsibilities for ongoing treatment _____

• Prescribed medication regimen _____

• Prescribed diet _____

• Benefits of disease management _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Disease Process

• Appraise the patient’s current level of knowledge related to specific disease process to establish knowledge basis for teaching.

• Describe disease process to ensure patient has adequate knowledge about the diseases and treatment.

• Describe the rationale behind management/therapy/treatment recommendations to enhance compliance with treatment.

• Reinforce information provided by other health care professionals.

• Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process.

• Instruct the patient on which signs and symptoms to report to health care provider to prevent complications.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 43-3 Patient With a Colostomy/Ileostomy

Nursing Diagnosis*

Risk for deficient fluid volume related to excess fluid loss from ileostomy, diarrhea from a colostomy, or inadequate oral intake

Patient Goals

1. Demonstrates no signs of hypovolemia

2. Maintains fluid and electrolyte balance

Outcomes (NOC)	Interventions (NIC) and Rationales
Fluid Balance • Blood pressure _____ • Radial pulse rate _____ • Peripheral pulses _____ • Skin turgor _____ • Moist mucous membranes _____ • Serum electrolytes _____ • 24-hr intake and output balance _____ • Stable body weight _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Hypovolemia Management • Observe for indications of dehydration (e.g., poor skin turgor, delayed capillary refill, weak/thready pulse, severe thirst, dry mucous membranes, decreased urine output, and hypotension) to determine presence of fluid volume deficit and, if present, plan appropriate interventions. • Monitor fluid status including intake and output to have an accurate record of fluid balance. • Encourage oral fluid intake (e.g., distribute fluids over 24 hr, give fluids with meals). • Maintain steady IV infusion flow rate to prevent dehydration. Fluid/Electrolyte Management • Monitor for abnormal serum electrolyte levels to detect any imbalances. • Maintain IV solution containing electrolytes at constant flow rate to replace lost electrolytes.

Outcomes (NOC)

Interventions (NIC) and Rationales

Fluid Balance

• Blood pressure _____

• Radial pulse rate _____

• Peripheral pulses _____

• Skin turgor _____

• Moist mucous membranes _____

• Serum electrolytes _____

• 24-hr intake and output balance _____

• Stable body weight _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Hypovolemia Management

• Monitor fluid status including intake and output to have an accurate record of fluid balance.

• Encourage oral fluid intake (e.g., distribute fluids over 24 hr, give fluids with meals).

• Maintain steady IV infusion flow rate to prevent dehydration.

Fluid/Electrolyte Management

• Monitor for abnormal serum electrolyte levels to detect any imbalances.

• Maintain IV solution containing electrolytes at constant flow rate to replace lost electrolytes.

Nursing Diagnosis

Risk for impaired skin integrity related to irritation from fecal drainage around peristomal area, irritation of appliance, and lack of knowledge of skin care

Patient Goal

Maintains intact, healthy skin around stoma

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes • Tissue perfusion (stoma) _____ • Sensation _____ • Skin integrity _____ • Skin temperature _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Ostomy Care • Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment to initiate treatment if indicated. • Apply appropriately fitting ostomy appliance to prevent drainage contact with skin. • Change/empty ostomy bag to prevent drainage leakage onto the skin. • Provide support and assistance while patient develops skill in caring for stoma/surrounding tissue to increase self-confidence. Skin Care: Topical Treatments • Refrain from using an alkaline soap on the skin to prevent skin irritation. • Initiate consultation services of the enterostomal therapy nurse to provide specialized teaching and care.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous Membranes

• Tissue perfusion (stoma) _____

• Sensation _____

• Skin integrity _____

• Skin temperature _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Ostomy Care

• Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment to initiate treatment if indicated.

• Apply appropriately fitting ostomy appliance to prevent drainage contact with skin.

• Change/empty ostomy bag to prevent drainage leakage onto the skin.

• Provide support and assistance while patient develops skill in caring for stoma/surrounding tissue to increase self-confidence.

Skin Care: Topical Treatments

• Refrain from using an alkaline soap on the skin to prevent skin irritation.

• Initiate consultation services of the enterostomal therapy nurse to provide specialized teaching and care.

Nursing Diagnosis

Deficient knowledge: ostomy care related to lack of exposure and unfamiliarity with information resources as evidenced by verbalization of lack of knowledge and inaccurate performance of care

Patient Goals

1. Describes the function of the ostomy and factors involved in the care and maintenance of the ostomy

2. Demonstrates use of equipment and removal and application of ostomy appliance

Outcomes (NOC)	Interventions (NIC) and Rationales
Ostomy Self-Care • Describes functioning of ostomy _____ • Measures stoma for proper appliance fit _____ • Maintains skin care around ostomy _____ • Empties ostomy bag _____ • Changes ostomy bag _____ • Uses correct irrigation technique (colostomy) _____ • Monitors for complications related to stoma _____ • Modifies daily activities to optimize self-care _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Ostomy Care • Instruct patient/significant other in the use of ostomy equipment and care. • Have patient/significant other demonstrate use of equipment to ensure proper technique for long-term care. • Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to obtain early treatment of complications. • Instruct patient/significant other in appropriate diet and expected changes in elimination function. • Teach patient to chew thoroughly, avoid foods that caused digestive upset in the past, add new foods one at a time, and drink plenty of fluids to help establish normal bowel patterns. • Encourage participation in ostomy support groups after discharge to help patient learn to live with an ostomy. • Express confidence that patient can resume normal life with ostomy to promote self-confidence.

Outcomes (NOC)

Interventions (NIC) and Rationales

Ostomy Self-Care

• Describes functioning of ostomy _____

• Measures stoma for proper appliance fit _____

• Maintains skin care around ostomy _____

• Empties ostomy bag _____

• Changes ostomy bag _____

• Uses correct irrigation technique (colostomy) _____

• Monitors for complications related to stoma _____

• Modifies daily activities to optimize self-care _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Ostomy Care

• Instruct patient/significant other in the use of ostomy equipment and care.

• Have patient/significant other demonstrate use of equipment to ensure proper technique for long-term care.

• Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to obtain early treatment of complications.

• Instruct patient/significant other in appropriate diet and expected changes in elimination function.

• Teach patient to chew thoroughly, avoid foods that caused digestive upset in the past, add new foods one at a time, and drink plenty of fluids to help establish normal bowel patterns.

• Encourage participation in ostomy support groups after discharge to help patient learn to live with an ostomy.

• Express confidence that patient can resume normal life with ostomy to promote self-confidence.

Nursing Diagnosis

Disturbed body image related to presence of ostomy and malodor as evidenced by verbalization of embarrassment or shame due to malodor and presence of stoma and refusal to participate in care or look at or touch stoma

Patient Goals

1. Verbalizes acceptance of changes in body appearance and function

2. Touches affected body part and participates in care of ostomy

3. Identifies methods to control ostomy odor

Outcomes (NOC)	Interventions (NIC) and Rationales
Body Image • Congruence between body reality, body ideal, and body presentation _____ • Attitude toward touching affected body part _____ • Adjustment to changes in physical appearance _____ • Adjustment to changes in body function _____ Measurement Scale 1 = Never positive 2 = Rarely positive 3 = Sometimes positive 4 = Often positive 5 = Consistently positive Ostomy Self-Care • Appears comfortable viewing stoma _____ • Avoids flatus-producing foods _____ • Avoids odor-producing foods ____ • Expresses acceptance of ostomy _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Body Image Enhancement • Help patient determine the extent of actual changes in the body or its level of functioning to assist with issues and misconceptions and plan appropriate interventions. • Monitor whether patient can look at the changed body part to assess readiness to participate in self-care. • Assist patient to separate physical appearance from feelings of personal worth to provide support and convey a sense of worth. • Facilitate contact with individuals with similar changes in body image to provide realistic experiences of having an ostomy. Ostomy Care • Instruct patient on mechanisms to reduce odor to minimize embarrassing odors from drainage. • Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to prevent odors and functional problems of ostomy. • Encourage patient/significant other to express feelings and concerns about changes in body image.

Outcomes (NOC)

Interventions (NIC) and Rationales

Body Image

• Congruence between body reality, body ideal, and body presentation _____

• Attitude toward touching affected body part _____

• Adjustment to changes in physical appearance _____

• Adjustment to changes in body function _____

Measurement Scale

1 = Never positive

2 = Rarely positive

3 = Sometimes positive

4 = Often positive

5 = Consistently positive

Ostomy Self-Care

• Appears comfortable viewing stoma _____

• Avoids flatus-producing foods _____

• Avoids odor-producing foods ____

• Expresses acceptance of ostomy _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Body Image Enhancement

• Help patient determine the extent of actual changes in the body or its level of functioning to assist with issues and misconceptions and plan appropriate interventions.

• Monitor whether patient can look at the changed body part to assess readiness to participate in self-care.

• Assist patient to separate physical appearance from feelings of personal worth to provide support and convey a sense of worth.

• Facilitate contact with individuals with similar changes in body image to provide realistic experiences of having an ostomy.

Ostomy Care

• Instruct patient on mechanisms to reduce odor to minimize embarrassing odors from drainage.

• Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to prevent odors and functional problems of ostomy.

• Encourage patient/significant other to express feelings and concerns about changes in body image.

^*Nursing diagnoses listed in order of priority.

eTABLE 43-1

ACUTE INFECTIOUS DIARRHEA: ETIOLOGY, SOURCES, AND TREATMENT

Type of Organism	Symptoms	Source of Infection/Susceptibility	Medication Treatment
Viral
Rotavirus	Fever, vomiting, and profuse watery diarrhea Lasts 3 to 8 days	Highly contagious Most U.S. children get it by age 2 yr Transmitted mainly by fecal-oral route	None, but vaccines RotaTeq and Rotarix are available for infants
Norovirus (also called Norwalk-like virus)	Nausea, vomiting, diarrhea, stomach cramping. Rapid onset Lasts 1-2 days	Very contagious Virus is present in stool and emesis	None
Bacterial
Enterotoxigenic Escherichia coli	Watery or bloody diarrhea, abdominal cramps Nausea, vomiting, and fever may be present Mean duration >60 hr	Most common cause of traveler’s diarrhea Transmitted in water or food contaminated with infected feces	Antibiotics, but antibiotic resistance is common
Enterohemorrhagic E. coli (e.g., E. coli O157:H7)	Severe abdominal cramping, bloody diarrhea, and vomiting Low-grade fever Usually lasts 5-7 days	Can cause serious illness in anyone, but the young and elderly are most susceptible May progress to life-threatening renal failure Transmitted in water or food contaminated with infected feces, especially undercooked ground beef	None See Table 42-24
Shigella	Diarrhea (sometimes bloody), fever, and stomach cramps Usually lasts 5-7 days Postinfection arthritis may occur	Transmitted via fecal-oral route from infected person to another, or in food or water contaminated with infected feces Can also contaminate recreational water	Usually none, but certain antibiotics (e.g., ampicillin, trimethoprim-sulfamethoxazole [Bactrim]) may shorten the length of illness
Salmonella	Diarrhea, fever, and abdominal cramps Lasts 4-7 days	Reservoir is poultry, reptiles, and other animals Turtles, lizards, snakes, chicks, and young birds are especially likely to harbor the organism Can be transmitted by handling the animals Found in undercooked poultry, meat, and foods prepared with raw eggs	Usually none Antibiotics are given if it spreads from intestine into bloodstream
Staphylococcus	Nausea, vomiting, abdominal cramps, and diarrhea Usually mild May cause illness in as little as 30 min Lasts 1-3 days	25%-50% of people are carriers in their mucous membranes, skin, or hair Most commonly transmitted in food contaminated by food workers who are carriers or through contaminated milk and cheese	Not affected by antibiotics
Campylobacter jejuni	Diarrhea, abdominal cramps, and fever. Sometimes nausea and vomiting Lasts about 7 days	Undercooked poultry and unpasteurized milk Most frequent in summer months	Erythromycin or fluoroquinolone are given in severe cases and to shorten duration of symptoms
Clostridium perfringens	Diarrhea, abdominal cramps, nausea, and vomiting Occurs 6-24 hr after eating contaminated food and lasts approximately 24 hr	Associated with meats, gravies, and stews; commonly associated with dried or pre-cooked foods Can cause serious illness in anyone, but the young and older adults are most susceptible.	None
Clostridium difficile	Watery diarrhea, fever, anorexia, nausea, abdominal pain	Prolonged use of antibiotics followed by exposure to feces-contaminated surfaces Spores on hands and environmental surfaces are extremely difficult to kill	Vancomycin (oral); metronidazole (Flagyl; oral or IV); fidaxomicin (Dificid) for recurrent infection
Parasitic
Giardia lamblia	Abdominal cramps, nausea, diarrhea May interfere with nutrient absorption	Highly contagious Transmitted via fecal-oral route and is also found in fresh lakes and rivers Most common intestinal protozoa worldwide Has been transmitted in swimming pools, water parks, and hot tubs	Metronidazole
Entamoeba histolytica	Diarrhea, abdominal cramping Only 10%-20% are ill, and symptoms are usually mild	Fecally contaminated food, water, or hands Most common in developing countries In the United States, high-risk groups include travelers, recent immigrants, and homosexual men	Antibiotics
Cryptosporidium	Watery diarrhea Lasts about 2 wk May also have abdominal cramps, nausea, vomiting, fever, dehydration, weight loss Sometimes no symptoms Long lasting and may be fatal in those who are immunocompromised (e.g., those with AIDS)	Lives in human intestines and is transmitted in stool of infected human or animal Outer shell allows it to live for long periods outside of body and makes it resistant to chlorine Common cause of waterborne disease (swimming pools, lakes, drinking water, food contaminated with feces)	Most with healthy immune systems recover without treatment Nitazoxanide (Alinia) for people with healthy immune systems Anti-retroviral therapy to improve immune function for those with AIDS