McMaster University NURSING 3104 

Identify Nursing Care Plan to the scenario

Assessment Data

Nursing Diagnosis

Planning ( goal )

Mrs. Rose is a 51- year- old female who is admitted to the medical surgical unit following a resection of the sigmoid colon and rectum due to a cancerous growth. She has a colostomy.

Mrs. Rose is married, has three children - two daughters, age 29 and 26, who are living on their own approx. 2 hours away and a son, age 20, who is in university and living at home.

Mrs. Rose had been in good health until January of this year when she noticed a decrease in appetite, abnormal bowel movements, varying from small hard stools to loose watery stools, and a sudden drop in weight of 9 lbs over 4 weeks. Mrs. Rose stated she had not been on a diet, had always struggled with her weight and was secretly elated when she began to lose weight with no effort.

Mrs. Rose is on a blood pressure medication and takes vitamin D and Calcium po daily. She has no known allergies.

 

Answer:

Nursing Care Plan : Since the patient has undergone colostomy, stoma (the opening in the skin where a pouch for collecting feces is attached) is created. Because of this, a good NCP for the case of the patient is about impaired skin integrity. 

1. Assessment Data:

       Objective cues: Presence of stoma in the right lower quadrant of the abdomen (say if the stoma is located there, ask your instructor if you can put a location of the stoma even if the exact location on the abdomen is not mentioned. If not, simply put presence of stoma (colostomy) on the patient's abdomen)

      The patient may manifest:? Pain, itchiness, swelling of the skin around the stoma

2. Nursing Diagnosis

         Impaired skin integrity related to mechanical factor colostomy

3. Planning ( goal )

       After 2 hours of nursing interventions, the patient shall participate in prevention measures and treatment program 

Step-by-step explanation

In order for you to answer these questions, you have to:

1. Read and analyze the case of the patient.

2. while reading, encircle or highlight the problem of the patient. This serves as your hint or basis in determining your NCP. In the case of the patient given above, aside from skin integrity problem, she is also risk for infection because of the surgical wound and stoma.

3. In doing your NCP, apply prioritization of the problem. I

4. you need to read articles or manual regarding the topic or case of the patient.