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Nursing Care Plan Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation
Nursing Care Plan Assessment Nursing Diagnosis Inference Planning Intervention Rationale Evaluation
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING
NAME OF STUDENT: Detablan, Aimee Kaileen S. YEAR/GROUP: 3-BN CONCEPT: Colostomy AREA: General Ward DATE: 25 September 2021
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Risk for Impaired Impaired skin integrity
Subjective Skin Integrity is a nursing diagnosis, Long Term Objective
Cues defined as alteration in
“Masakit siya nurse” the epidermis and/or
verbalized by the dermis. The skin is
patient when asked subject to injury from a
about his colostomy variety of external and
of his abdomen internal factors.
Friction, shear,
moisture, pressure,
Objective and trauma are all
Cues causes of skin
-Reddish stoma breakdown. These
with reddish factors can work
surrounding skin together or alone to Short Term Objective
damage and injure
Vital signs: skin. Immobility, poor
BP: 130/80 mmHg nutrition, incontinence,
P: 79 beats per min medications,
R: 20 bpm hydration, impaired
T: 36.6 C mental status, and loss
O2 Sat: 100% of sensation are other
culprits in skin
breakdown.
Referrence:
https://medical-
dictionary.thefreedictio
nary.com/impaired+ski
NAME OF PATIENT:_________________________________ AGE:_______________
CLINICAL IMPRESSION/DIAGNOSIS:______________________________ CHIEF COMPLAINT:_________________________________
REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING
n+integrity#:~:text=imp
aired%20skin
%20integrity%20a
%20nursing,of
%20external%20and
%20internal
%20factors.
Reference: