Nursing Care Plan
A Client with Colorectal Cancer
William Cunningham adalah 65 tahun pensiunan kereta
api karyawan, suami, dan ayah dari tiga
anak-anak yang sudah dewasa. Selama 3 bulan terakhir, Mr. Cunningham telah
melihat sejumlah kecil darah dalam tinja dan lendir sesekali. Dia memiliki sensasi
tekanan pada rektum, dan pemberitahuan bahwa bangku nya lebih kecil dengan
diameter, tentang ukuran pensil. Setelah meraba massa pada pemeriksaan digital
rektum, dokter memerintahkan kolonoskopi. Sebuah lesi sessile besar ditemukan
dalam rektum dan laporan biopsied.The patologi menunjukkan lesi menjadi
adenokarsinoma. Mr. Cunningham dijadwalkan untuk reseksi dan sigmoid
abdominoperineal kolostomi.
PENILAIAN
Madonna Hart, RN, completes the admission assessment. Mr. Cunningham
states that his bowel habits have recently changed, but denies pain or other
symptoms. Physical assessment findings include T 98.4 F (36.9° C), P 82, R 18,
and BP 118/78. He is 70 inches (178 cm) tall and weighs 185 lb (84 kg).
Laboratory findings are normal except for the previous pathology report of
adenocarcinoma of rectal lesion.
Mr. Cunningham states, “I really don’t want a colostomy, but if that is what it
takes to get rid of this, I’m ready to get it over with.”
DIAGNOSIS
Ms. Hart identifies the following nursing diagnoses for Mr. Cunningham.
• Pain, related to surgical intervention
• Risk for impaired skin integrity (peristomal), related to fecal drainage and
pouch adhesive
• Risk for constipation/diarrhea, related to effects of surgery on bowel function
• Risk for disturbed body image, related to colostomy
• Risk for sexual dysfunction, related to wide rectal incision, radiation therapy,
and colostomy
EXPECTED OUTCOMES
The expected outcomes specify that Mr. Cunningham will:
• Report pain within an acceptable range that allows ease of movement and
ambulation.
• Perform colostomy care using correct technique.
• Demonstrate willingness to discuss changes in sexual function.
• Wear clothing to enhance physical and emotional self-esteem.
PLANNING AND IMPLEMENTATION
Ms. Hart plans and implements the following nursing interventions for Mr.
Cunningham.
• Provide analgesia as ordered, evaluating its effectiveness.
• Discuss foods that cause odor and gas.
• Teach colostomy care.
• Maintain consistent nursing personnel assignment to facilitate trust.
• Refer to the local United Ostomy Association.
• Provide a list of local medical supply companies for ostomy supplies.
• Provide for privacy when teaching and discussing concerns about ostomy.
EVALUATION
On discharge, Mr. Cunningham is able to empty and rinse out his colostomy
pouch. He is changing the pouch and caring for surrounding skin
appropriately.Ms.Hart has given him verbal and written instructions on colostomy
care.He verbalizes understanding of phantom rectal pain, and the importance of
avoiding rectal temperatures and rectal suppositories. He expresses an
understanding of the need to avoid heavy lifting, and the importance of follow-up
care.Ms.Hart has referred Mr.Cunningham to a home health agency in his
community for further questions and follow-up care.
Critical Thinking in the Nursing Process
1. What is the cause of phantom rectal pain?
2. Why is it important to discuss dietary concerns with a client with a
colostomy, especially odor- and gas-forming foods?
3. Outline a plan to teach Mr. Cunningham how to irrigate a colostomy.
4. Develop a care plan for Mr. Cunningham for the nursing diagnosis, Body
image disturbance.
See Evaluating Your Response in Appendix C.