Subjective	Objective
Complaints of shortness of breath	Dyspnea; orthopnea; increased respiratory rate; decreased depth of breathing; decreased minute ventilation; decreased vital capacity; nasal flaring; use of accessory muscles to breathe; altered chest excursion; pursed-lip breathing; decreased oxygen saturation; arterial blood gas (ABG) values: respiratory acidosis

RISK FACTOR:

• Abdominal injury

DESIRED OUTCOMES: The client will maintain an effective breathing pattern as evidenced by:

a. Normal rate and depth of respirations

b. Absence of dyspnea

NOC OUTCOMES: Respiratory status: ventilation

NIC INTERVENTIONS: Ventilation assistance; respiratory monitoring

Nursing Diagnosis RISK FOR IMBALANCED FLUID VOLUME NDx; RISK FOR ELECTROLYTE IMBALANCE^* NDx

Definition: Risk for developing an imbalance of electrolytes and fluids in the intracellular and extracellular compartments of the body.

Related to:

• Deficient fluid volume NDx related to excessive blood loss, loss of fluid associated with vomiting and nasogastric tube drainage (if present)

• Hypokalemia and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with blood loss, vomiting, and nasogastric tube drainage

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of nausea; headache	Hypotension; tachycardia; prolonged capillary refill >2 to 3 seconds; decreased urine output; vomiting; abnormal serum electrolyte levels; flat neck veins when client is flat; increased urine specific gravity; increased blood urea nitrogen (BUN) and hematocrit (Hct) values

RISK FACTORS:

• Injury

• Possible surgical procedure

• Ineffective fluid level and electrolyte replacement therapy

DESIRED OUTCOMES: The client will maintain fluid and electrolyte balance as evidenced by:

a. Blood pressure (B/P) and pulse within normal range for client and stable with position change

b. Capillary refill time less than 2 to 3 seconds

c. Usual mental status

d. Balanced intake and output

e. Urine specific gravity within normal range

f. Soft, nondistended abdomen with active bowel sounds

g. Absence of cardiac dysrhythmias, muscle weakness, paresthesias, twitching, spasms, and dizziness

h. BUN, Hct, serum electrolyte, and ABG values within normal range

NOC OUTCOMES: Fluid balance; electrolyte and acid-base balance

NIC INTERVENTIONS: Fluid management; electrolyte management: hypokalemia; electrolyte management: hypocalcemia; acid-base management: metabolic acidosis

Nursing Diagnosis INEFFECTIVE PERIPHERAL TISSUE PERFUSION NDx

Definition: Decrease in blood circulation to the periphery that may compromise health

CLINICAL MANIFESTATIONS:

Subjective	Objective
Complaint of nausea, abdominal pain, or tenderness; complaint of dizziness and lightheadedness	Hypoactive or absent bowel sounds; nausea; abdominal distention; abdominal pain or tenderness; tachycardia; hypotension; cyanotic, pale skin; oliguria; capillary refill time greater than 2 to 3 seconds; elevated BUN and serum creatinine level; decreasing oxygen saturation

RISK FACTORS:

• Decreased cardiac output

• Trauma

• Inadequate therapeutic regimen

DESIRED OUTCOMES: The client will maintain adequate tissue perfusion as evidenced by:

a. B/P within normal range and stable with position change

b. Usual mental status

c. Extremities warm with absence of pallor and cyanosis

d. Palpable peripheral pulses

e. Capillary refill time less than 2 to 3 seconds

f. BUN and serum creatinine levels within normal limits

g. Urine output at least 30 mL/h

NOC OUTCOMES: Circulation status; tissue perfusion: abdominal organs; tissue perfusion: cardiac; tissue perfusion: cerebral; tissue perfusion: peripheral; tissue perfusion: pulmonary

NIC INTERVENTIONS: Circulatory care: arterial insufficiency; circulatory care: venous insufficiency; cerebral perfusion promotion; hypovolemia

Nursing Diagnosis ACUTE PAIN NDx

Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Related to:

• Injury

• Surgery

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal report of pain	Grimacing; diaphoresis; changes in B/P; tachypnea; tachycardia; restlessness; grading behaviors

RISK FACTORS:

• Abdominal trauma, bleeding into the abdomen, and surgical intervention

DESIRED OUTCOMES: The client will experience diminished pain as evidenced by:

a. Verbalization of decrease in or absence of pain

b. Relaxed facial expression and body positioning

c. Increased participation in activities

d. Stable vital signs.

NOC OUTCOMES: Pain control: comfort level

NIC INTERVENTIONS: Analgesic administration; pain management; patient-controlled analgesia (PCA) assistance

Collaborative Diagnosis RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum

• Exposure of abdominal contents to pathogens associated with a penetrating abdominal wound

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of increasing abdominal pain, rebound tenderness, and nausea	Temperature above 38° C; rigid abdomen; diminished or absent bowel sounds; tachycardia; hypotension; tachypnea; elevated white blood cell (WBC) count

RISK FACTOR:

• Exposure to pathogens

DESIRED OUTCOMES: The client will not develop peritonitis as evidenced by:

a. Temperature stable and less than 38° C

b. Soft, nondistended abdomen

c. No increase in abdominal pain and tenderness, nausea, and vomiting

d. Normal bowel sounds

e. Stable vital signs

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of peritonitis (e.g., further increase in temperature or temperature above 38° C; distended, rigid abdomen; increase in severity of abdominal pain; rebound tenderness; increased nausea and vomiting; diminished or absent bowel sounds; tachycardia; tachypnea; hypotension; a WBC count greater than 15,000/mm³).	Early recognition of signs and symptoms of peritonitis allows for prompt intervention.

Collaborative Diagnosis RISK FOR SEPTIC SHOCK

Definition: A life-threatening medical condition that involves decreased tissue perfusion resulting from a systemic infection

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Hypotension; tachycardia; widening pulse pressure; restlessness; warm, flushed skin; change in level of consciousness; capillary refill greater than 2 to 3 seconds; significant decrease in pulse oximetry values; changes in arterial blood gas values

RISK FACTORS:

• Trauma

• Infection

• Decreased cardiac output

• Failure of regulatory mechanisms

DESIRED OUTCOMES: The client will not develop septic shock as evidenced by:

a. Systolic B/P equal to or higher than 90 mm Hg

b. Usual mental status

c. Urine output at least 30 mL/h

d. Extremities warm and usual color

e. Capillary refill time less than 2 to 3 seconds

f. Palpable peripheral pulses

Collaborative Diagnosis RISK FOR ORGAN ISCHEMIA/DYSFUNCTION (MULTIPLE ORGAN DYSFUNCTION SYNDROME [MODS])

Definition: A life-threatening syndrome in which the body is unable to maintain homeostasis without intervention

• Microvascular thrombosis associated with disseminated intravascular coagulation (DIC) if it occurs

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Severe hypotension; tachycardia; urine output less than 30 mL/h; dyspnea, tachypnea; altered arterial blood gas values with low PaO₂; elevated BUN and serum creatinine levels; crackles throughout lungs; changes in mental status

RISK FACTORS:

• Decreased cardiac output

• Infection

• Decreased vascular fluid volume

• Failure of regulatory mechanisms

DESIRED OUTCOMES: The client will not develop organ ischemia or dysfunction as evidenced by:

a. Usual mental status

b. Urine output at least 30 mL/h

c. Unlabored respirations at 12 to 20 breaths/min

d. Audible breath sounds without an increase in adventitious sounds

e. Absence of new or increased abdominal pain, distention, and diarrhea

f. BUN, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) levels within normal range

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE HEALTH MANAGEMENT^* NDx

Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/treatment/lifestyle changes; pattern of regulating and integrating into family processes a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals; inability to identify, manage, and/or seek out help to maintain health

CLINICAL MANIFESTATION:

Subjective	Objective
Requests information; client statements reflect misunderstanding	Inadequate follow through of instruction; inappropriate or exaggerated behaviors

RISK FACTORS:

• Cognitive limitations or unfamiliarity of situation

NOC OUTCOMES: Knowledge: treatment regimen; knowledge: health behavior; knowledge: health resources

NIC INTERVENTIONS: Health system guidance; teaching: individual; teaching: prescribed activity/exercise; teaching: prescribed medications

NURSING ASSESSMENT

	RATIONALE
Assess client’s willingness to learn and knowledge related to the disease process.	The client’s willingness to learn and knowledge base provides the basis for education.
Assess for indications that the client may be unable to effectively manage the therapeutic regimen.	Early recognition of inability to understand disease process or self-care allows for change in the teaching plan.

APPENDICITIS/APPENDECTOMY

Acute appendicitis is one of the most common indications for emergency abdominal surgery. The appendix is a small fingerlike pouch that extends from the inferior part of the cecum and is usually located in the right iliac region. The most common cause of appendicitis is obstruction of the lumen by a fecalith, a foreign body, an appendiceal calculus, a tumor, or intramural thickening caused by lymphoid hyperplasia. Obstruction of the appendix leads to increased luminal pressure, vascular congestion, bacterial invasion, and ultimately, necrosis and perforation of the appendix.

An appendectomy is the surgical removal of the appendix. It can be done via a laparotomy or laparoscopy. A laparoscopic appendectomy offers the advantage of shorter hospitalization and decreased morbidity and mortality but is contraindicated in persons with extensive intraperitoneal adhesions or other intestinal problems that would impede mobilization and dissection of the appendix.

This care plan focuses on the adult client with suspected appendicitis who is hospitalized for a possible appendectomy.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have evidence of normal healing of surgical wound

2. Have clear, audible breath sounds

3. Tolerate prescribed diet

4. Have surgical pain controlled

5. Have no signs and symptoms of postoperative complications

6. State signs and symptoms to report to the health care provider

7. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, medications prescribed, activity level, and wound care.

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

An ileostomy is the diversion of the ileum from the abdominal cavity through an opening created in the abdominal wall. It may be performed after abdominal trauma or to treat conditions such as familial polyposis, intestinal cancer, and most commonly, inflammatory bowel disease that is refractory to conservative management. An ileostomy can be temporary or permanent.

A temporary ileostomy is usually created to allow the bowel to heal after traumatic abdominal injury or to permit healing of a newly constructed ileoanal reservoir (pouch). The ileoanal reservoir is a treatment option for some persons with inflammatory bowel disease or familial polyposis. In the initial surgery, the diseased portion of the intestine is removed, a temporary ileostomy is performed, and a reservoir is created in the rectal area using a portion of the ileum. After 2 to 4 months, the ileostomy is closed and intestinal continuity is established between the remaining intestine and the ileoanal reservoir.

There are two types of permanent ileostomies. The conventional (Brooke) ileostomy is the most common one. It is created by bringing a portion of the terminal ileum through the abdominal wall, usually in the right lower quadrant. The ileostomy drains intermittently but, because it cannot be regulated, a collection device needs to be worn over the stoma at all times. Another type of permanent ileostomy is the continent ileostomy. In this procedure, the terminal ileum is used to construct an intra-abdominal reservoir (Kock pouch). Initially, the reservoir drains via a catheter that is placed through the stoma and a surgically constructed one-way valve. After the surgical area heals, the catheter is removed and the reservoir only needs to be drained periodically. If the system functions properly, the client does not need to wear a collection device over the stoma. The type of permanent ileostomy constructed depends on the client’s age, underlying disease process, and preference and expertise of the surgeon. A proctocolectomy (removal of the colon, rectum, and anus) is often done at the same time as a permanent ileostomy to treat the disease process or to prevent future bowel changes that could occur. If a proctocolectomy is not performed, the rectal stump is sutured across the top; the rectum stays intact and secretes mucus that is expelled via the anus.

This care plan focuses on the adult client with inflammatory bowel disease hospitalized for bowel diversion with creation of a permanent ileostomy. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have surgical pain controlled

2. Have evidence of normal healing of the surgical wound

3. Have a medium pink to red, moist stoma and intact peristomal and perianal skin

4. Have no evidence of fluid and electrolyte imbalances

5. Maintain an adequate nutritional status

6. Have no signs and symptoms of postoperative complications

7. Verbalize a basic understanding of the anatomical changes that have occurred as a result of the bowel diversion

8. Identify ways to maintain fluid and electrolyte balance

9. Verbalize ways to maintain an optimal nutritional status

10. Identify methods of controlling odor and sound associated with ileostomy drainage and gas

11. Demonstrate the ability to change the pouch system, maintain integrity of the peristomal and perianal skin, and maintain adequate stomal integrity

12. Demonstrate the ability to properly use, clean, and store ostomy products

13. Demonstrate the ability to drain and irrigate a continent ileostomy if present

14. Identify ways to prevent and treat blockage of the stoma

15. State signs and symptoms to report to the health care provider

16. Share thoughts and feelings about the effect of altered bowel function on self-concept and lifestyle

17. Identify appropriate community resources that can assist with home management and adjustment to changes resulting from the bowel diversion

18. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, wound care, activity level, and medications prescribed.

USE IN CONJUNCTION WITH STANDARDIZED PREOPERATIVE CARE PLAN

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx

Definition: Absence or deficiency of cognitive information related to a specific topic

RISK FACTORS:

• Lack of knowledge regarding the surgical procedure, physical preparation for the bowel diversion, sensations that normally occur after surgery and anesthesia, expected appearance and function of the ileostomy, and postoperative care and management of the ileostomy

NOC OUTCOMES: Knowledge: treatment regimen; knowledge: treatment procedure(s)

NIC INTERVENTIONS: Health system guidance; teaching: individual; teaching: procedure/treatment

NURSING ASSESSMENT

	RATIONALE
Assess client’s understanding of surgical procedure and outcome.	Client’s understanding of what may occur will decrease anxiety.

THERAPEUTIC INTERVENTIONS

USE IN CONJUNCTION WITH POSTOPERATIVE CARE PLAN

Nursing Diagnosis RISK FOR IMBALANCED FLUID VOLUME NDx; RISK FOR ELECTROLYTE IMBALANCE^* NDx

Definition: Risk for developing an imbalance of electrolytes and fluids in the intracellular and extracellular compartments of the body

• Restricted oral fluid intake before, during, and after surgery

• Blood loss

• Loss of fluid associated with vomiting, nasogastric tube drainage, and/or high-volume ileostomy output

Hypokalemia, hypomagnesemia, and hypochloremia related to loss of electrolytes associated with vomiting, nasogastric tube drainage, decreased oral intake, and/or high-volume ileostomy output

Metabolic alkalosis related to:

• Loss of hydrochloric acid associated with vomiting and nasogastric tube drainage

• Loss of bicarbonate ions associated with high-volume ileostomy output (effluent contains bicarbonate ions that would normally be absorbed throughout the large intestine)

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal reports of weakness; confusion, nausea	Change in mental status; decreased skin turgor; postural hypotension; weak, rapid pulse; decreased urine output; cardiac dysrhythmias; nausea and vomiting; absent bowel sounds; decreased urine output; capillary refill ≤ 2-3 seconds; decreased electrolyte levels, decreased pH and CO₂ levels; positive Chvostek’s and Trousseau’s sign

RISK FACTORS: