Clinical Protocol: Acute Surgical Wound

SWCCAC New Ostomy Toolkit - Care Plan Page 1 of 2

Client Name: ______

Assessment: Complete nursing agency history, physical, psychosocial and wound assessments, Identify client’s learning style:
Auditory Visual Kinesthetic Read & write (see key page 2 for definitions) / Date Completed/ Initials
Client Self Management: Provide client with copy of handouts: “My Ostomy Care” PLUS “My Ileostomy” or “My Urostomy” or “My Colostomy”
In chart below and on page 2, record date when taught or date when teaching was reinforced along with initials and designation. Add client response.
Client’s Goals: 1.______
2.______
3.
Objectives: (Note- “Client” includes the individual, the family and/or care providers)

Client will describe how, when and whom to call when problems occur by end of first visit.

Client will understand the role of the ET/Ostomy Specialty nurse by the end of the first visit.

Client will describe surgery– related pain as a score of 3/10 or less with appropriate use of analgesia/adjunctive/alternative methods by end of the first visit.

Client will verbalize that he/she has the necessary comfort/understanding/ knowledge to express and report pain by end of first visit.

*Client will be able to describe S&S of wound infection /identify resources within “My Ileostomy /Urostomy/Colostomy” by end of first visit.

Client with new ileostomy will be able to identify High Fibre foods that must be avoided for 6-8 weeks, need for fluid replacement and signs and symptoms of fluid and electrolyte imbalance by the end of the first visit.

Client with new urostomy will be able to identify S&S of UTI by end of the first visit.

*Client will be able to identify factors contributing to delayed healing / SSI and contribute to plan of care to address these factors by end of the first week.

Nurse will evaluate client’s flex clinic eligibility by the end of the second week or sooner.

*Client will be independent in self-management of their ostomy by______(date) by performing total pouching changes independently.

On discharge, client will be given the discharge materials, including “Discharge Instructions for Clients with New Ostomies”

*Note: When objectives 1-11 are met, but the stoma is still expected to change over the normal 6-8 week period, the visit frequency should be reduced to weekly, with a review of when to contact the nurse as outlined in “My Ileostomy /Urostomy/Colostomy”.
Reporting: Wound Care Status Reports are done on initial visit and then q 3 weeks thereafter while wound is considered healable.
Ostomy and Wound Treatment (if wound present): Care Plan is comprehensive and follows RNAO Clinical Best Practice Guidelines Ostomy Care and Management . Utilize your nursing agency Flowsheet/ Ostomy Treatment Plan.

Nurse’s Signature/Designation InitialsNurse’s Signature/Designation InitialsNurse’s Signature/Designation Initials

______

SWCCAC Ostomy Toolkit - Care Plan

Page 2 of 2

Client Name: ______

Object-ive (from page 1) / Content Outline / Method of instruction / Time allocate-ed / Resources / Method of evaluation / Date Taught / Nurse
Initials / Date reinforce-ed / Nurse
Initials / Client response
4. / Further review of the signs and symptoms of Surgical Site Infection (SSI) “My Ileostomy /Urostomy/Colostomy”. / 1:1 instruction, discussion / 2 min / Page 7 / Question and answer
5&6 / Further review of low-fibre diet and need for fluid/electrolyte replacement for clients with ileostomy “My Ileostomy” / 1:1 instruction, discussion / 5 minutes / Pages 9-13 / Question and answer
10. / Demonstrate proper technique according to the ‘My Ostomy care’ document / Demonstration, return demonstration / 10min / “My Ostomy Care” &
ostomy care supplies / Observation of return demonstrat-ion

Additional Planning:

Nurse’s Signature/Designation InitialsNurse’s Signature/Designation InitialsNurse’s Signature/Designation Initials

______

SWCCAC Ostomy Toolkit - Care Plan – Feb. 22, 2012