BSN 2020

NURSING PROCESS CARE PLAN

Student __________
Date 5/29/20

NURSING DIAGNOSIS: Impaired Skin Integrity r/t disruption of skin from the surgical procedure, sigmoid colostomy formation, and potential skin
irritation from feces and colostomy appliance

PRIORITY # 1
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
Subjective and Objective Data 1 Client Goal Interventions Actual Completion of Nursing Goal Evaluation
Subjective Objective (Goal must be timed and (3 Nursing Interventions with Interventions (met, not met, partially met
measurable) SMART Rationale and Reference for each) and explanation)

Patient states, Ostomy Patient will remain free 1) Drain and change ostomy 1) Followed proper Goal has been met. Patient
“There might be assessment: the from skin irritation and pouch in timely manner and procedures and demonstrates ability to
(leakage from or ostomy pouch is breakdown around when necessary to prevent techniques to change discern between what’s
around the half full with ostomy pouch throughout possible leakage and ostomy pouch, normal and what’s abnormal.
pouch)” and brown liquid stool a 12 hour shift overuse of one ostomy bag cleansed the skin, and Area of skin around the stoma
states the area and there is some 2) Assess skin integrity around applied a new bag remains free from breakdown
around the pouch stool leaking ostomy pouch and keep area 2) Assessed stoma and throughout the 12 hour shift
is “a bit tender between skin and clean and free from leakage area around the pouch
sometimes”. skin barrier to prevent possible skin for signs of infection
breakdown or skin breakdown.
3) Educate the patient and Cleansed area with
demonstrate self-care warm tap water and
behaviors that effectively soap as needed. Made
manage the ostomy to help sure to dry completely
patient identify possible risk before applying a new
factors for skin breakdown ostomy bag
3) Taught patient how to
make necessary
observations, to be
aware of indications
of problems, how to
respond to these
problems as they
arise, and to recognize
when to seek

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 BSN 2020

assistance

* Cite all interventions/rationales per APA format

NURSING DIAGNOSIS: Disturbed Body Image r/t presence of permanent colostomy

PRIORITY # 2
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
Subjective and Objective Data 1 Client Goal Interventions Actual Completion of Nursing Goal Evaluation
Subjective Objective (Goal must be timed and (3 Nursing Interventions with Interventions (met, not met, partially met
measurable) SMART Rationale and Reference for each) and explanation)

Patient states, “I Patient spoke in a Patient will be more 1) Educate patient about the 1) Taught patient to keep Goal partially met. Although
am embarrassed quiet tone and comfortable and various methods of odor bag clean and sealed all interventions were
about the smell” avoided eye knowledgeable about control well, encourage foods completed, patient still states
when asked how contact when they how to live a normal life 2) Educate patient about that help deodorize they are “not comfortable
they are feeling. talked about the with an ostomy by the physical activities they can feces and foods that with the colostomy bag”.
smell end of the 12 hour shift or cannot partake in reduce gas. Also However, patient is more
3) Provide resources to patient taught that there are knowledgeable about the
regarding physical and odor control products ostomy and how they are able
psychological support they available for purchase to live a normal life with it
can find 2) Taught patient that
they can resume
normal activity such
as work and sexual
relations. They can
also exercise, but they
should refrain from
direct contact sports
and heavy lifting
3) Provided resources to
patient regarding
community groups

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 BSN 2020

and answered
questions patient had
about these support
groups

* Cite all interventions/rationales per APA format

References

Taylor, C., Lynn P., Bartlett, J. L. (2018). Fundamentals of nursing (9th ed.). Wolters Kluwer. Retrieved from

https://coursepoint.vitalsource.com/#/books/9781975101336/

5/2020 SHM