The nurse is caring for a male client postoperatively following the creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?
A. Sexual dysfunction
B. Body image, disturbed
C. Fear related to poor prognosis
D. Nutrition: more than body requirements, imbalanced
Correct Answer: B. Body image, disturbed
Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). Encourage the patient/SO to verbalize feelings regarding the ostomy. Acknowledge normality of feelings of anger, depression, and grief over a loss. Discuss daily “ups and downs” that can occur.
Option A: Review with the patient and/or SO sexual functioning in relation to their own situation. Understanding if nerve damage has altered normal sexual functioning helps the patient/SO to understand the need for exploring alternative methods of satisfaction.
Option C: Provide opportunities for patient/SO to view and touch stoma, using the moment to point out positive signs of healing, normal appearance, and so forth. Remind the patient that it will take time to adjust, both physically and emotionally.
Option D: Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis. Recommend patient increase use of yogurt, buttermilk, and acidophilus preparations. Identify odor-causing foods (e.g., cabbage, fish, beans) and temporarily restrict them from the diet. Gradually reintroduce one food at a time.
No comments:
Post a Comment