- Deficient Knowledge related to Misinterpretation of information and Inadequate participation in care planning as evidenced by Nonadherence with the treatment regimen and Inaccurate follow-through of instructions
- Ineffective Breathing Pattern related to Increased abdominal pressure and Abdominal pain, or discomfort as evidenced by Shortness of breath and Hyperventilation
- Ineffective Tissue Perfusion related to inflammatory process and Obstruction as evidenced by Abdominal distension and Abdominal discomfort
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Inadequate commitment to learning -Inadequate awareness of resources -Inadequate information -Lack of a support system Objective data: -Nonadherence with the treatment regimen -Inaccurate follow-through of instructions -Inaccurate statements about a topic -Development of a preventable complication | Deficient Knowledge related to Misinterpretation of information and Inadequate participation in care planning as evidenced by Nonadherence with the treatment regimen and Inaccurate follow-through of instructions | Patient will verbalize understanding of the condition, its complications, and the treatment regimen. Patient will participate in care planning and follow-up appointments. | 1. Discuss diet and comorbidities. Since bowel obstructions, impaction, and diverticulitis can all lead to bowel perforations, the patient should be instructed on consuming a proper diet, such as increased fiber intake and plenty of fluids if not contraindicated. 2. Discuss symptoms that require immediate medical attention. Signs and symptoms like worsening abdominal pain and discomfort, chills, fever, nausea and vomiting, and purulent drainage with edema and erythema around the surgical site must be reported, as this can indicate developing complications. 3. Prepare the patient for surgery. Bowel perforation may be treated through a laparoscopic procedure, or endoscopy, or if severe, may result in a colostomy. Prepare the patient for what to expect with their procedure by encouraging and answering questions. 4. Encourage the patient to follow up with care. Monitoring after surgical intervention for bowel perforation is essential to avoid complications like a fistula or hernia. | Patient verbalized understanding of the condition, its complications, and the treatment regimen. Patient participated in care planning and follow-up appointments. |
| Subjective data: -Difficulty breathing; shortness of breath or dyspnoea -Anxiety in relation to breathing Objective data: -Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Restlessness and anxiety -Decreased level of consciousness Diaphoresis | Ineffective Breathing Pattern related to Increased abdominal pressure and Abdominal pain, or discomfort as evidenced by Shortness of breath and Hyperventilation | Patient will demonstrate a normal breathing pattern and show no signs of respiratory distress. Patient will exhibit ABGs within acceptable limits. | 1. Monitor the patient’s oxygen saturation continuously. Dyspnea and other alterations in breathing patterns associated with bowel perforation and increased intra-abdominal pressure can cause hypoxia. Normal oxygen saturation is between 95% to 100%. SpO2 less than 90% can indicate significant oxygenation problems. 2. Monitor and evaluate blood gas values. Blood gas values can indicate imbalances in carbon dioxide, oxygenation, and pH levels of the blood and can signify developing complications for patients with bowel perforation. Normal blood gas values include PaO2 80-100 mmHg, PaCO2 35-45 mmHg, HCO3 22-26 mEq/L, and pH 7.35-7.45. 3. Administer supplemental oxygenation. Initial management for bowel perforation includes aggressive resuscitation, including oxygen therapy, intravenous fluids, and administration of broad-spectrum antibiotics. Oxygen supplementation can help correct hypoxemia or hypoxia. 4. Administer medications as indicated. Pain medications can help relieve abdominal pain and reduce dyspneic episodes caused by bowel perforation and abdominal discomfort. | Patient demonstrated a normal breathing pattern and show no signs of respiratory distress. Patient exhibited ABGs within acceptable limits. |
| 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 Inflammatory process and Obstruction as evidenced by Abdominal distension and Abdominal discomfort | Patient will remain free from abdominal distention and discomfort. Patient will remain free from gastrointestinal tissue perfusion complications like peritonitis, bleeding, and septic shock. | 1. Administer intravenous fluid replacement. Initial management of bowel perforation involves establishing hemodynamic stability and preventing complications like septic shock. 2. Administer medications as indicated. Early initiation of antibiotic therapy is essential in preventing infection, reducing inflammation, and promoting adequate gastrointestinal tissue perfusion. 3. Prepare the patient and assist in surgical intervention. In severe cases, laparoscopic or traditional open surgery may be indicated to remove the perforated part of the bowel and reconnect it. 4. Perform proper stoma care. In some cases, bowel perforation surgeries will require the creation of the stoma to allow the resected bowel to rest and heal before it will be reattached. The nurse will monitor the stoma following surgery for complications such as bleeding, necrosis, retraction, and prolapse that inhibit perfusion. 5. Monitor for any signs of complications. The nurse should monitor the patient for signs of complications like bowel obstruction, fistula formation, and hernias. Symptoms such as absent bowel sounds, increased pain, and changes in vital signs signal abnormalities in perfusion. | Patient remained free from abdominal distention and discomfort. Patient remained free from gastrointestinal tissue perfusion complications like peritonitis, bleeding, and septic shock. |