Basa,Darianne Badenas

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Risk for impaired After 3 days of Independent:

“Binutasan po yung skin integrity comprehensive  Inspect stoma or  Monitors skin healing and Goal was met as
tiyan ko kasi related to nursing skin area in every identify areas of concern. evidenced by absence of
nahihirapan po improperly fitting intervention, the pouches change. rashes and skin irritations
akong tumae” –as appliance patient’s stoma around the stoma and
verbalized by the (improvised and the  Clean with warm  Maintain clean area and was able to identify
patient. colostomy bag). surrounding parts water or NSS. prevent skin breakdown individual factors that
will be free from may contribute to skin
possible rashes or  Instruct to apply  Protects skin from adhesive breakdown.
Objective data: irritations. skin barrier like and waste enzyme
• Presence of karaya powder to irritation.
transverse colostomy the surrounding
at right abdominal skin area.
area.
• Generalized  Evaluate adhesive  Determines need for
weakness noted. products and evaluation.
• Poor self hygiene appliance fit on
• Improvised ongoing basis.
colostomy bag
Dependent:

 apply antifungal  Assist in healing if irritation

powder as persist.
prescribed.

Bachelor of Science in Nursing III Ostomy

Basa,Darianne Badenas
 Bachelor of Science in Nursing III NGT

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Risk for aspiration After 8 hours of  Assess  to rule out hypoactive After 8 hours of nursing
Objective data: related to nursing gastrointestinal peristalsis nursing and interventions, the patient
Neuromuscular interventions, the function abdominal distension was able to have normal
 With NGT for dysfunction patient will be able breath sounds or no
feeding to have normal  Position patient  to prevent gastric reflux change in patient’s
 Minimize gag breath sounds or with head it bed through gravity baseline breath sounds
reflex no change in elevated 30
patient’s baseline degrees
breath sounds
 Maintain patency  to prevent accumulation of
and functioning of gastric contents
nasogastric
suction apparatus

 Provide frequent  to prevent colonization of

and scrupulous the oropharynx with
mouth care bacteria and noculation of
the lower airways

 Ensure that  to limit aspiration of

endotrachea oropharyngeal secretions.
tracheostomy cuff
is properly
inflated