ASSESSMENT DATA NURSING DIAGNOSIS PLANNING NURSING EVALUATION

(Appropriate data to support (Must include scientific Goals (include realistic short IMPLEMENTATION (Actual outcome of care and
nursing diagnosis, include rationale for the diagnosis, and long term (What actually was done, must appropriate follow-up actions)
subjective and objective data) include references*) client-centered goals) include scientific rationale with  Goals
 Short Term/Long Term references and delegation of  Implementations
 Interventions tasks*)
50 year old male admitted to Risk for Impaired Skin Short term: 1. Assisted/taught patient while 1. Patient correctly drained
hospital with Sigmoid colon Integrity •During my shift, the ostomy draining colostomy bag before colostomy device when
cancer R/T: Bowel Diversion ostomy and surrounding skin will ½ full- nursing task/ not partially full- follow up with
intact without signs of delegated patient throughout shift to offer
Client stated “I haven’t been “fecal material from a breakdown. assistance
that hungry the last few colostomy is irritating to the Rationale: “weight of an overly
months” peristomal skin, any irritation Long term: full bag may loosen the skin
or skin breakdown needs to be •In two weeks the ostomy site barrier and separate it from the
Abnormal Lab: treated immediately” (Kozier and surrounding skin will be skin causing the stool to leak
HGB 11.5 L and Erb, 2008 p.1345) intact and without signs of and irritate the peristomal
breakdown. skin” (Kozier and Erb, 2008
HCT 33.6 L •After teaching session the p.1347)- Initially performed by
client and wife will be able to RN to properly teach client,
RBC 3.49 L perform colostomy care with then can be delegated to LPN
correct technique. or CNA
Lymphoc 17.7 L
yte Intervention: 2. client cleansed stoma and 2. client properly cleanse
Calcium 8.1 L •keep skin clean by washing peristomal skin with warm peristomal skin and stoma
off and excretions (use warm water, and pat dry. Initial while changing ostomy device-
Protien 5 L water) and drying thoroughly nursing task/ CNA delegated further education needed to
(pat dry) help patient prepare for
Albumin 2.5 L •Stoma care: wearing clean Rationale: “stool can irritate discharge
gloves while changing a non- peristomal skin” (Kozier and
Current body weight 156 drainable pouch, Erb, 2008 p.1347) “excess
Ideal body weight 172 lbs= •washing/drying skin rubbing can abrade the skin”
5’11’, 16 lbs under IBW thoroughly, (Kozier and Erb, 2008
•empting pouch at 1/2-1/3 full, p.1348)- Initially performed by
Newly placed transverse while empting pouch place a RN to properly teach client,
Colostomy device tissue or gauze over stoma to then can be delegated to LPN
absorb secretion, or CNA
Pain scale at 4 •assess Skin the of the stoma
for active bleeding, ulceration, 3. Assessed speristomal site for 3. Peristomal skin and stoma
darker-colors with bluish hue, irritation, redness, ulceration, was free from signs of irritation
note burning sensation bleeding, and color while and breakdown. Patient and
simultaneously teaching client wife correctly identified

Imbalance Nutrition: Less
than body requirements
R/T: Inadequate absorption of
nutrients
AEB: Indication of low protein
and albumin levels from CBC
“Because there is so much
albumin in the body and
because it is not broken down
very quickly, albumin levels
change slowly. Thus, a low
level serum albumin level is a
useful indicator of prolonged
protein depletion.” (Kozier
and Erb, 2008 p.1259)
Short term:
•client will be able to select
appropriate meal options to
achieve needed protein intake
by the end of client teaching
Long term:
•client will gain 2 pounds in
one week
•clients total protein and
albumin levels increase in two
weeks
Interventions:
•asses clients food preference
•consult with dietician
•perform a nutritional
assessment
•avoid unpleasant or
uncomfortable treatments
immediately before or after
meals
•provide familiar foods in
accordance with full liquid diet
•full diet client teaching
and wife the importance of important signs of breakdown
good skin integrity and how to and irritation (redness,
maintain it (e.g. cleansing inflammation, burning,
ostomy and surrounding skin bleeding, change in color)
when changing colostomy bag,
keeping site free of stool,
detecting signs of tissue
breakdown) -Not delegated
Rationale: “It is important to
assess the peristomal skin for
irritation” (Kozier and Erb,
2008 p.1345)
1. client selected liked foods
1. client selected foods liked form full diet list
from full liquid diet to eat the
following day- Delegated,
nursing follow up
Rationale: “Provide familiar
food that the person likes.
Often the relatives o clients are
pleased to bring for from home
but need some guidance about
special diet requirements”
(Kozier and Erb, 2008 p.1263)
2. client properly selected
2. assisted client with proper foods higher in protein to eat –
food selections for full liquid follow up with client to plan
diet that are rich in protein- for appropriate foods to eat
Nursing task/ Dietician task after discharge on regular diet
Rationale: “client teaching:
health nutrition, discuss foods
high in specific nutrients
required such as protein, iron, \
calcium, vitamin C, and fiber”
(Kozier and Erb, 2008 p.1261)
3.client was taught to keep a
3. provided client teaching on food frequency record to track
 •Advance to soft diet as
tolerated
•client food frequency record
•client teaching protein and
nutrient rich foods
•monitor CBC (protein and
albumin)
•weekly weighing of client
Pain
Related to Post operation
placement of transverse Short Term:
ostomy •Patient will self identify pain
AEB paitent stating “after level at or below comfort level
moving around I am really during my shift
hurting”
Long Term:
food frequency record to help consumption of protein and
log protein intake- Nursing nutrient rich foods
task
Rationale: “when specific
foods or nutrients are
suspected of being deficient or
excessive, the health care
professional may use a
selective food frequency.”
(Kozier and Erb, 2008 p.1257)
4. client is underweight- client
4. calculated clients ideal body teaching needed for guidance
weight- Delegated, Nursing in gaining healthy weight
follow up
5’11”= 172 lbs
Rationale: “Ideal body weight
is the optimal weight
recommended for optimal
health” (Kozier and Erb, 2008
p.1236)
5.clients weight was 156 no
5. weighed client to determine gain/loss- daily assessment
gain/loss needed
“dietary guidelines for
Americans; maintain weight in
a healthy range”
(Kozier and Erb, 2008
p.1246)
1. client voice understanding of
1.taught client 0-10 pain scale- pain scale- discontinue
delegated teaching
“to avoid confusion scales
should us a 0-10 range with 0
indication no pain and highest
number indicating worst pain
“pain is an unpleasant sensory
and emotional experience
associated with actual or
potential tissue damage”
**Low self-esteem related
to Ostomy
**Disturbed Body Image
related to Ostomy
**Anxiety related to lack of
control of fecal elimination
secondary to ostomy
•Until discharge patient will
maintain comfort level with the
use of non pharmacological
pain relief
Intervention:
•Using Non Pharmacological
pain relief
•Teach pain scale
•Distraction
•Hot/Cold therapy
•Assess Pain
•Reduce stress
•Emotional support
possible”
(Kozier and Erb 2008, p.1198)
2.Assessed clients pain using 2. client’s pain scale was at a 4
0-10 scale, nursing task after ambulating in hallway-
refused analgesic, further
“perception is reality, client’s assessment needed
self-report of pain is what must
be used to determine pain
intensity”
(Kozier and Erb 2008, p.1198)
3. talk with patient about
3.Provided emotional support- problems he was having at
nursing task home with his children-
continue with implementation
“Therapeutic communication
with an emphasis on listening
providing encouragement
teaching etc. promote coping”
(Kozier and Erb 2008, p.1221)
4. client performed crossword
4.Wife provided client with for an hour, during this time I
newspaper and crossword assessed his pain level pain
puzzle to work-can be done my level, client stated it was at a 2-
family or nurse contiue with non
pharmacological pain relief
“Distraction allows the
person’s attention away from
the pain and lessens the
perception of pain” (Kozier
and Erb, 2008 p.1220)