- Diarrhoea Related to Colorectal tumour and fluid leakage as evidenced by abdominal cramping and bowel urgency
- Dysfunctional gastrointestinal motility related to inflammatory process and changes in eating habits as evidenced by abdominal cramping and distended abdomen
- Ineffective Tissue Perfusion related to Cancer progression and damage to the gastrointestinal tract as evidenced by Hypoactive bowel sounds and change in bowel habits
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Abdominal pain -Gas, bloating -Urgency and frequency Objective data: -Hyperactive bowel sounds -Three or more loose stools per day -Blood or mucus in the stool | Diarrhoea Related to Colorectal tumour and fluid leakage as evidenced by abdominal cramping and bowel urgency | Patient will maintain the perianal area free from any irritation or breakdown. Patient will utilize medications to control diarrhoea and symptoms as prescribed. | 1. Monitor intake and output. Diarrhea can cause dehydration. Monitoring the patient’s intake and output can help monitor the patient’s fluid status and prevent dehydration. 2. Encourage fluid intake as indicated. Adequate fluid intake can improve bowel consistency and promote hydration. 3. Refer the patient to a dietitian. Colorectal cancer patients may need specialized meals to help ensure adequate dietary intake and facilitate recovery. Some foods may need to be avoided to reduce gastric irritability. 4. Encourage perianal skin care. Diarrhoea can cause altered skin integrity in the perineal/rectal area. Instruct on proper cleaning and comfort with the use of medicated or wet wipes and barrier creams. 5. Administer medications as needed. Antidiarrheal medications are prescribed to help relieve symptoms of diarrhoea. | Patient maintained the perianal area free from irritation or breakdown. Patient utilized medications to control diarrhoea and symptoms as prescribed. |
| Subjective data: Verbalizes abdomen distention Objective data: -Abdominal pain -Abdominal cramping -Absence of flatus -Altered bowel sounds -Diarrhoea -Distended abdomen -Difficulty defecating -Nausea -Vomiting | Dysfunctional gastrointestinal motility related to inflammatory process and changes in eating habits as evidenced by abdominal cramping and distended abdomen | Patient will be free from abdominal distention, cramping, and pain. Patient will demonstrate active bowel sounds with at least three formed stools per week. | 1. Encourage a high-fiber diet. Patients with colon cancer are encouraged to eat high-fiber foods like lentils, whole grains, and fruits to aid the passage of food through the intestines and reduce problems related to dysfunctional gastrointestinal motility. 2. Encourage the patient to exercise as indicated. Digested food moves through the gastrointestinal tract through a series of muscle contractions. Exercising promotes peristalsis and increases metabolism reducing problems with gastrointestinal motility in patients with colon cancer. 3. Encourage adequate fluid intake. Adequate fluid intake keeps the stool soft, improves transit time, and reduces gastrointestinal motility problems. Dehydration can cause the intestinal walls to contract slower, making the bowels sluggish. 4. Prepare and assist in surgical intervention. Depending on the stage of cancer, a colon resection may be required to remove the tumor and affected parts of the colon to promote normal gastrointestinal function. 5. Provide ostomy care and patient education and support. Normal bowel function can be preserved through a colostomy, where the colon is reconnected to the abdominal surface by creating a stoma. The nurse educates the patient and families on how to care for their colostomy. | Patient free from abdominal distention, cramping, and pain. Patient demonstrated active bowel sounds with at least three formed stools per week. |
| Subjective data: Chest Pain Dyspnoea Sense of impending doom Objective data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Tissue Perfusion related to Cancer progression and damage to the gastrointestinal tract as evidenced by Hypoactive bowel sounds and change in bowel habits | Patient will remain free from any signs of perfusion complications, such as rectal bleeding, abdominal distension, vomiting, or severe abdominal pain. Patient will exhibit active bowel sounds with the absence of abdominal pain and bloating. | 1. Assist in radiation therapy. Preoperative radiation therapy can help control tumor growth and metastasis to other organs, ultimately reducing tissue perfusion complications. 2. Assist and prepare the patient for surgical removal of the tumor. Surgical resection of the tumor in the colon is considered the best method for the removal of colon cancer and for improving tissue perfusion in the gastrointestinal tract. The type of procedure performed will depend on various factors, including the size, location, extent of metastasis, integrity of the bowel, and the patient’s overall condition. 3. Administer chemotherapy as indicated. Adjuvant chemotherapy is indicated after surgical removal of the tumor for patients with stage II or stage III colon cancer. This treatment will interrupt the DNA production of cancer cells and destroy them, preventing colon cancer recurrence and gastrointestinal complications, including perfusion problems. 4. Intervene promptly if serious complications are suspected. If signs of peritonitis, obstruction, or perforation are suspected, the nurse and healthcare team must quickly intervene. These complications often manifest as sudden and severe abdominal pain, distension, fever, loss of flatus or bowel movements, and nausea and vomiting. | Patient remained free from any signs of perfusion complications, such as rectal bleeding, abdominal distension, vomiting, or severe abdominal pain. Patient exhibited active bowel sounds with the absence of abdominal pain and bloating. |