NURSING PROBLEM: Disturbed Body Image related to presence of stoma, loss of control of bowel elimination AEB verbalization of

negative feelings about body, fear of rejection/reaction of others.

ASSESSMENT

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EXPECTED
OUTCOME

Disturbed Body

The client with

ostomy faces
o Assess
Image related to
Subjective
After 1 hour of
alterations in
perception of
presence
of
Cues:
self-concept and
nursing
change in
body image. This
structure or
stoma; loss of
Tinatago ko
intervention, the
body image is
function of
control
of
bowel
yung supot,
the attitude a
client will:
body part
person has about
nakakahiya kase elimination AEB
Verbalize
the
verbalization of
acceptance
kapag makita
actual/perceived
of self in
structure
negative feelings
ng ibang tao
situation,
or function of all
about body, fear
may dumi ko,
or part of the
incorporatin
of
body. This
g change
as verbalized by
attitude is
o Explain to
into selfrejection/reaction
the patient
dynamic and is
patient the
concept
of others.
altered through
importance of
without
interaction with
the procedure
negating
other people and
to aid in
self-esteem.
situations as an
recovery.
Objective
Demonstrate
important
acceptance
Cues:
part of ones self
by touching
concept. Body
o Presence of
the stoma
image
descending
disturbance can
and
have profound
o Encourage

o The extent
of
response
is more
related to
the value
of
importanc
e the
patient
places on
the part.
o Providing
informatio
n to the
patient
can
somehow
enhance
well being
and
outlook.
o Patient

After 1 hour of
nursing
intervention the
client shall have
o Verbalized
acceptance of
self in situation
AEB
expression of
feelings about
stoma.
o Demonstrated
acceptance of
stoma AEB
touching and
participating
in self care.

colostomy
at left
abdominal
area.

impact on how
individual view
their overall self

participating
in self-care.

verbalization
of feelings
towards
change in
body image.

o Refusal to
touch the
stoma
o Hesitant
during
inspection.
o Hides the
stoma using
clothes.

needs to
recognize
feelings
before
they can
be dealt
with
effectively.

o Assess
perceived
o To
impact of
determine
change on
how the
ADLs, social,
patient
behavior and
acts to
personal
changes.
responsibilities
o Provide
opportunities
for patient/SO
to view and
touch stoma,
using the
moment to
point out
positive signs
of healing,
normal
appearance,
and so forth.

o Touching
stoma
reassures
patient/S
O that it is
not fragile
and that
slight
movement
s of stoma
actually
reflect

normal
peristalsis.

o Advise SO to
provide
support and
enhance
interaction
with patient.

o Distortions
in body
image
may be
unconscio
usly
reinforced
by the
family.

o Plan/schedule
care activities
with patient.

o Promotes
sense of
control
and gives
message
that
patient
can
handle
situation,
enhancing
selfconcept.

NURSING PROBLEM: Risk for impaired skin integrity related to improperly fitting appliance (improvised colostomy bag)
ASSESSMENT

Subjective
Cues: Makati
yung garter lalo
na pag
pinagpapawisan
ako, prang
matatanggal sa
pagkakalagay,
as verbalized by
the client

Objective
Cues:
o Presence of
descending

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EXPECTED
OUTCOME

o Assess skin,
A colostomy is a
o Establish
After 1 hour of
After 1 hour
surgical
noted color,
comparative nursing intervention
impaired skin
procedure that
of nursing
turgor sensatio
baseline
the client shall have
brings
a
portion
of
integrity
n; describe
intervention,
providing
o Maintained skin
the large intestine
and measure
related to
opportunity
integrity around
through the
the client will:
stoma and
for timely
the stoma.
abdominal wall to
improperly
o Determine
observe
carry out feces out
intervention.
o Demonstrated
fitting
technique
of the body. In the
changes
behavior or
s
on
how
case of the
appliance
techniques on
to keep
patient, due to
o Instruct the
(improvised
o Skin friction
how to keep
the improper
the stoma
patient to
caused by
the stoma free
colostomy bag)
fitting of the
free from
maintain clean
stiff or
from rashes and
colostomy bag,
rashes and
and dry
rough
irritations like
waste product of
irritations
clothes
the colon may
clothes
proper stoma
like proper
leak out into the
preferably
leads to
care and
stoma
surrounding skin
cotton fabric.
irritation and
emptying.
care and
of the stoma and
increase risk
emptying
it may cause
for infection.
irritation, itchiness
and rashes to the
o Advise patient o This may
skin.
not touch nor
increase the
Risk for

scratch the

colostomy at

peristomal

risk for

left

area with bare

infection.

abdominal

hands.

area
o Generalized
weakness
noted
o Itchiness on
the
surrounding

o Demontrate

o To provide

peristomal

proper

area cleaning

ostomy care

using clean

and prevent

water/ NSS

complicatio

before a new

ns

pouch is
applied.

of the stoma
o Improvised

o Educate the

o To increase

patient that

patients

the pouch

awareness

bag and

should be

on proper

garter as a

changed every

ostomy care.

colostomy

holder.

4-5 days when

leakage
occurs.
o Teach the

o The client

patient to

should

empty pouch

demonstrate

when it is

the ability to

about half full

empty and

including

change the

proper

pouch

emptying.

independen
tly before
being
discharge

o Consult with

o May be

certified

helpful in

wound ostomy

choosing

if persistence

producrs for

of rashes is

healing

present.

rehabilitatio
n