Priority Decision-Making discussion post - Nursing

I am submitting three individual discussion post and I need you to respond to each one individually and provide constructive and insightful comments that go beyond that of agree or disagree. 1)This post is from Claire:Disturbed Body Image would be the priority nursing diagnosis for this patient. Prior to surgery the patient would've been educated about his/her disease, treatment, and the procedure which would be performed, therefore deficient knowledge would not be a priority at this time. Post surgery the patient's concern would be about his/her disturbed body image, as a 22yr old single and young person body image is of highest concern. The patient had ulcerative colitis, according to (Smeltzer et al 2010) is a reccurrent and inflammatory disease of the mucosal and submucosal layers of the colon and rectum. It is a chronic condition that has periods of exacerbations and remissions (flare-ups) (Smeltzer et al 2010). The patient would have bloody diarrhea, pain, anemia (iron deficiency), and electrolyte imbalance. Medications are given to decrease symptoms and treat inflammation, but when non-surgical treaments fail, the recommended management is surgery. Proctocolectomy with ileostomy was performed on this patient, which involved complete excision of the colon, rectum, and anus. The ileostomy allows effluent drainage of feces from the ileum to the outside of the body, which disturbs the appearance of this patient's body image (Smeltzer et al 2010). There are considerations that should be involved in the dicision making process regarding priority of care for the patient: (1) Prevention of ulceration, excoriation, and irritation from effluent (drainage). (2) Patient should become proficient in self-care and activities of daily living should include ostomy care. (3) Patient should be educated on skin protection (skin barrier), pouch care (empty when 1/3 full, know when to change bag), know the name of the supply company and names of supplies), diet (chew food thoroughly, avoid high fiber foods), medications (avoid capsules, notify pharmacist of ostomy). (4) Teach signs and symptoms of complications which should be reported to physician. (5) Consideration and assessment of patient's lifestyle, family and friends support. Referral should be made to support groups and arrange for consult with WOC nurse. Evaluation should reveal the patient engaging in self-care, maintaining peristomal skin integrity, and verbalize signs and symptoms of complications. Their behavior should demonstrate integration of ostomy care into their lifestyle. 2)This post is from Brook:. A 22 yo male who just had an evasive surgery as in proctocolectomy with ileostomy would need education as priority inclusive of what to expect after and how to care for it. However, this can change upon assessment of the patient before or after surgery occurs. What considerations are involved when making decisions about priority of patient care? The patient may or may not make statements or actions that show concern about the ileostomy. He might completely avoid talking about the procedure or make negative remarks displaying crying, anger, or laughing. He might also display a positive attitude that's realistic about recovery, or ask many questions appearing anxious or afraid. The nurse must consider are all signs indicative of disturbed body image or deficient knowledge and address the needs before and after surgery. Within that he/she can evaluate/ re-evaluate and implement the correct goals with the patient resulting in higher patient outcomes. How would the nurse evaluate whether the priority decision for this situation was patient centered? The nursing diagnosis can go hand in hand, while the nurse is teaching about care for the ileostomy the patient might start making remarks that show he is going threw the stages of grief, in which is normally expected however, depression or the inability to move threw the stages require special observation by the nurse. Cultures where ones appearance is of high value put a patient at high risk for disturbed body image and can be addressed before surgery. The patient is 22 and can have great concern about his sex life or activities ie: working out, swimming,; its important that he feels comfortable enough to discuss his concerns and the nurse actively listens and supports the patient by encouragement and positive remarks. The nurse will need to pay close attention to the verbal and non-verbal cues of the patient before and after the procedure, asking questions when appropriate. I don't think medicine/ nursing is black or white and care plans need to be adjusted according to the patients needs, with doing so the nurse can re- evaluate if the interventions are correct for the patient at the time. According to this scenario and the little information that is given I would start with education then I would evaluate the patients mind, body, and soul re- evaluating accordingly, making adjustments to interventions and outcomes as needed. Deficient Knowledge: The nurse would teach the patient after surgery: Dietary modifications related to nutritional status and presence of ileostomy. Provide referral to dietitian for diet planning and teaching. Teach importance of maintaining a high fluid intake and manifestations of dehydration. Teach to empty and change ostomy pouch of choice. Teach stoma and peristomal skin assessment with each pouch change. Teach food blockage management. Refer to local United Ostomy Association. Provide list of local medical suppliers for ostomy appliances. 3)This post is from Marita: The patient is a single, 22 year old who has just had a proctocolectomy with formation of ileostomy due to a 4 year history of ulcerative colitis. The assignment is to choose which nursing diagnosis is priority for our patient. Disturbed body image or deficient knowledge. The registered nurse (RN) develops a care plan for a patient using the nursing process. Assessment is the first step in developing a plan of care and this will include subjective and objective data, previous and current medical history and a physical assessment. The information gathered will help the nurse prioritize care for the patient. The RN can use Maslow's hierarchy of needs as a framework to help determine which need should be fulfilled first. Maslow believed that basic needs must be met before moving to the next level. Basic or physiological needs include food, shelter, water, sleep, oxygen and the need to eliminate and dispose of bodily wastes. I believe deficient knowledge would be the priority nursing diagnosis for our patient. The patient will need education on managing dietary and fluid needs to be able to eliminate and dispose of bodily wastes. The first 6-8 weeks after surgery the diet has to be strained fruits and vegetables. Foods are reintroduced one at a time and there will be certain foods the patient will need to avoid such as a high fiber diet, popcorn, celery and seeds. Fluid lost through perspiration can add to the fluid lost through the ileostomy, so during summer months the patient may need Gatorade to maintain electrolyte balance (Smeltzer, Hinkle, Bare & Cheever, 2010). Dietary modifications will be necessary for the patient to eliminate and dispose of bodily wastes. Nursing diagnoses focus on the patients response to their medical condition. When making a plan of care the RN needs to consider which nursing diagnosis is more important to fulfill first. The assessment of the patient will assist the RN to determine what the priority will be. This includes the patients physiological needs as well as psychological needs. The patient is single and 22 years old. According to Erik Erickson's stages of social growth and development, this is a time when young adults form intimate, loving relationships. Success leads to strong relationships, while failure leads to loneliness and isolation (Fontaine, 2009). A patient that has not been given the proper education about dietary changes after this surgery will not be able to eliminate and dispose of bodily wastes properly, so this may lead to social isolation. A person who is not able to eliminate bodily wastes properly will not want to give or receive affection and will not want companionship. I understand that the patient with disturbed body image may also isolate themselves from friends, relationships and family. This made it difficult to choose which nursing diagnosis would be priority. Maslow's hierarchy of needs assisted me to determine the priority for our patient. The RN can evaluate whether the priority decision for this situation was patient centered by setting clear, concise goals that are measurable, observable and time limited. The goals should be realistic and determined by the patient, family and nurse.