ASSESSMENT NURSING DIGAGNOSIS

CLIENTGOAL

NURSINGINTERVENTION

RATIONALE OUTCOME CRITERIA

EVALUATION

S: “Gibuslotan

akong tiyan kay maglisod kog kalibang,” as verbalized by patient.

O: Presence of

transverse colostomy at right abdominal area.

Generalized weakness noted.

Poor self hygiene.

Improvised colostomy bag.

No karaya powder or egg white applied.

Risk for impaired skin integrity related to improperly fitting appliance( improvised colostomy bag).

Scientific Basis:Due to the improper fitting of colostomy bag, waste product of the colon may leak out into the surrounding skin of the stoma and it may cause possible irritation, itchiness or

After 3 days of comprehensive nursing intervention, client’s stoma and the surrounding parts will be free from possible rashes or irritations.

Independent:-inspect stoma or skin area in every pouches change.-clean with warm water or NSS.- instruct to apply skin barrier like karaya powder to the surrounding skin area.-evaluate adhesive products and appliance fit on ongoing basis.Dependent:-apply antifungal powder as prescribed.Collaborative:-consult with certified wound ostomy if persistence of rashes is present.

-monitors skin healing and identify areas of concern.-maintain clean area and prevent skin breakdown.-protects skin from adhesive and waste enzyme irritation.-determines need for evaluation.

-assist in healing if irritation persist.

-helpful in choosing products for healing rehabilitation.

Patient will manifest the following:

1. Maintain skin integrity around stoma.

2. Identify individual risk factors.

3. Demonstrate behavior or techniques to promote healing and prevent skin break down.

4. Absence of rashes and skin irritation around the stoma.

Goal was met as evidenced by absence of rashes and skin irritations around the stoma and was able to identify individual factors that may contribute to skin breakdown.

rashes to the skin.