implementing measures colostomy and ileostomy care

1. colostomy undertaking maintenance and ileostomy

1. 1. Greetings therapeutic delivered to the client / family friendly
        upon meeting
1.2. Action plan described to the client / family understand
1.3. Program plan validated again
1.4. The need for tools and materials are identified
1.5. Readiness client be re-examined

 
2. preparing patients
2.1. Describe the action procedure to be performed
2.2. Assess the patient's readiness and participation
 2.3. Give the patient tone privacy by locking doors or curtains / blinds
2.4. Assist patient in a comfortable position
- Tracheotomy semi-Fowler position
- Colostomy and colostomy supine position
3. carry out preparatory tool
3.1. Treatment colostomy
- Colostomy bag
- Plastic bags for dirty place
- Hydrogen Piroksida (H 0)
- Tweezers anatomically I
- Tweezers cirugis 2
- Com sterile
- Drug disinfectant (Bethadine)
- Scissors
- Plaster hypo allergic
- Sterile Gauze
- pedestal

- Nierbekken
3.3. Treatment illeostomy
- Physiological fluid (NaCl, Normal Copy)
- Tweezers anatomical 1
- Tweezers cirugis 2
- Com sterile
- Drug disinfectant (bethadine)
 - Scissors
- Plaster hypo allergic
- Sterile Gauze
-pedestal
- Kasa suppressor (deeper)
- Handscoen 1 pair
- curtain
- Nierbekken
4. action procedures
4.1. colostomy care

 

- Assist patients in a comfortable position, supine
- Laying the pad under the patient's back
- Put sampiran
- Nurses wash their hands and put handscoen
- Removing the bandage and the old colostomy bag and put it into a dirty plastic bag
- Clean the wound with H 0 and using sterile physiological fluids, repeat until clean
- Dry the wound using sterile gauze
- Measure the stoma mouth, according to a large mouth plastic bag and place directly on the skin
- Removing handscoen
- Glue the end of the plastic bag on the skin with a plaster hypoallergenic
- Equipment cleared
- Position the patient is returned to the original position
- Nurses wash their hands
4.2 ileostomy care

- Assist patients in a comfortable position, supine
- Laying down the back of the patient pengalas
- Put sampiran
- Nurses wash their hands and wear handscoen
- Conducting exploitation ileostomy
- Remove the dirty bandage and place it on nierbekken
- Clean the wound using sterile physiological fluids and repeat
                                                                        until clean
- Blood Drain-wound with a sterile gauze cloth using
- Wound smeared with a solution desinfecktan, Bethadine and closed view of sterile gauze and plaster
- Handscoen opened.
- Equipment to clean
- The patient's position on the starting position is returned
- Nurses wash their hands
5. documentation

• Documented patient response
• The timing of the nursing assessment
• Documentation note with clear / easy to read
• Documentation signed and the full name and clearly

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give oxygen through a nasal canul

1. patient preparation

• Greetings therapeutic delivered to the client / family friendly upon meeting
• Action plan described to the client / family understand
• Prograrn plan validated again
• The need for tools and materials are identified
• Readiness client be re-examined

2. preparation tool
2.1. Prepared with a complete tool

• Nasal Canula
• Oxygen tubing (hose O)
• Humidifier
• Sterile Water
• Tube O (source O) and flowmeter
• Label "No Smoking"

2.2. The tools are neatly
2.3. The tools brought to near patient
3. action procedures

 

1. View client for signs of hypoxia and the presence of secretions in the airway
2. hand washing
3. Lengketkan sign "no smoking" on the door or in the patient's room where it can be seen patients and visitors (paste in a tube O)
4. Show Canula nasal to the patient and explain the procedure
5. Make sure the humidifier filled with limits specified in sterile water
6. Connect the hose O between nasal canule with humidifier
7. Set the flow rate - the average O accordance with the instructions of the doctor / min. Feel the flow at the end of Canula
8. Place the tip of Canula into the nostril (breathing) patients
9. Set up Canula efastis testers actually locked and comfortable and sturdy
10. Check Canula every 8 hours
11. Keep the humidifier bottle containing all the time
12. Observation nostril (lobe, sputum and nasal external) patients and areas above both ears, from the irritation caused by hose Canula, every 6-8 hours
13. Check the flow rate doctor's instructions 02 and every 8 hours
14. wash your hands

4. documentation

• Documented patient response
• The timing of the nursing assessment
• Documentation note with clear / easy to read
• Documentation signed and the full name and clearly

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attention to cultural and religious values

1. Patient preparation

• Greetings therapeutic delivered to the client / family friendly upon meeting
• Action plan described to the client / family understand
• Program plan validated again
• The need for tools and materials are identified
• Readiness client be re-examined

 2. Action procedures

 

• Taking into account the principle of fairness in providing nursing actions
• Taking into account the principle of respect for autonomy (the right to Determine the action of self / client)
• Cost-benefit principle nursing actions given to clients and avoid disability
• Taking into account the principle of honesty (telling the true and honest to the client)
• Taking into account the principle of commitment (action taken should be based on responsibility, moral and professional)
• 2.6. Noting the basis of religion joints (norms, culture and religion are the foundation is maintained in the conduct of nursing actions

3. Ddocumentation

• Documented patient response
• The timing of the nursing assessment
• Documentation note with clear / easy to read
• Documentation signed and the full name and clearly

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implement teraupetik communication in nursing practice

1. Patient Preparation

• Greetings therapeutic delivered to the client / family friendly upon meeting
• Action plan described to the client / family understand
• Program plan validated again
• The need for tools and materials are identified
• Readiness client be re-examined

2. preparation tool

• Stationery

3. Action procedures
3.1. Pre Phase Interaction

 

• Prior to the nurse's therapeutic communication with patients prior explore feelings and fantasies
• Analyze the strengths and weaknesses professional nurse herself
• Nurses get data about clients if possible planned first meeting

 

3.2. Introductory phase (orientation)

• Regards therapeutic
• Introduce yourself to the patient
• Starting interaction with patients by providing an opportunity to start a conversation
• Nurse and patient have agreed to communicate more openly
• Declare a contract with
• Exploring the thoughts, feelings and actions of the client
• Asking the client issues
• Formulating goals with clients

3.3. Phase Work

• Using komunication to improve patient dignity
• Evaluate the patient's ability to communicate verbally
• Identifying the developmental level of the patient so that the interactions are expected to be realistic
• Determine whether the patient is demonstrating verbal and non-verbal corresponding
• Assess the patient's level of anxiety that can identify intervention needed
• Increase the independence and self-responsibility, develop constructive coping mechanisms

3.4. Phase Termination

• Terminate the duty nurse or client home
• Nurses and clients create a reality that can not be denied farewell
• Nurses and clients alike with ¬ reviewing treatment processes that have been passed and the achievement of goals
• Nurses and clients develop coping for farewell and express feelings.
• Say hello cover

4. documentation

• Documented patient response
• The timing of the nursing assessment
• Documentation note with clear / easy to read
• Documentation signed and the full name and clearly

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