ASSESSMENT NURSING SCIENTIFIC GOALS INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
SUBJECTIVE An ileostomy is a After 16 hours of Independent -After 16 hours of
CUE: Risk for impaired surgical procedure nursing intervention 1. Establish rapport 1. To gain the patient and nursing intervention
tissue Integrity that brings a portion the patient will be patient’s S.O‘s trust and the patient was able to:
“Gin-operahan ako related To of the small intestine able to: cooperation.  Participate in
ha ak tiyan dapit adi Mechanical through the  Participate in prevention
man mayda ko factors—surgical abdominal wall to preventive measures and
gihapon tubo kanan trauma to tissues as carry out feces out measures and 2. Monitor vital signs 2. To obtain baseline data. treatment program
akon colostomy evidenced by of the body. treatment
bag.” As verbalized presence of incision Ileostomy are program 3. Assess general 3. To determine interventions
by the patient. and ostomy bag. created to divert condition needed by the client.  Maintain intact
stool from diseased  Maintain intact skin.
portion of the skin.
OBJECTIVE intestine allowing 4. Assess if client is at 4. Presence of comorbidities
CUE: rest and healing. It is risk for delayed (e.g., diabetes, COPD,  Demonstrate
- Colostomy done by accurate  Demonstrate healing. anemia, obesity, behaviors or
bag placed at depiction of behaviors or malnutrition, and techniques to prevent
RLQ with colorectal surgery techniques to prevent alcoholism) can impact complications.
greenish beginning with complications. healing.
output and at midline incision,  Change stoma
LLQ with then ileum is cut to pouch independently.  Change stoma
orange- allow insertion of a 5. Inspect incision 5. Early recognition of pouch independently.
colored catheter, the skin  Promote timely regularly, noting delayed healing or
output and tissues then are wound healing characteristics and developing complications  Promote timely
closed around the integrity. may prevent a more serious wound healing
- Presence of new opening called situation.
stoma at the stoma.
LLQ and
RLQ of the
both pinkish 6. Observe wounds, 6. Close observation of
in color. noting characteristics surgical dressings
of drainage promotes early

- Limited
range of
motion 7. Encourage side-lying 7. Promotes drainage from
noted. position with head
elevated. Avoid
- Incision prolonged sitting.
noted at the
midline.
8. Maintain patency of
drainage tubes; apply 8.
collection bag over
drains or incisions in
presence of copious
or caustic drain.
identification of problems,
such as hematoma
formation, outright
bleeding.
perineal wound/drains,
reducing risk of pooling.
Prolonged sitting increases
perineal pressure, reducing
circulation to wound, and
may delay healing.
Facilitates approximation
of wound edges; reduces
risk of infection and
chemical injury to skin and
tissues.

9. Caution client 9. Prevents contamination of

not/minimize area.
touching the
incision.

10. Instruct patient that 10. To provide proper ostomy

the peristomal area care and prevent
must be cleaned well complications.
with mild soap and
dried before new
pouch is applied.
11. Impart patient 11. Increase patient’s
teachings with knowledge on proper
emphasis on: ostomy care.

12. Changing the pouch

every 4-5 days or 12. The client should
when leakage occurs. demonstrate the ability to
empty and change the
pouch independently
13. Emptying the pouch before being discharged.
when it is about half
full and cleaning the 13. Proper nutrition increases
pouch properly when chances of faster recovery/
emptying it. wound healing.

14. Importance of 14. Skin friction caused by

nutrition especially stiffed or rough clothes
fluids, protein, leads to irritation and
vitamin C, vitamin increases risk of infection.
B., iron and
potassium rich foods.

15. Instruct patient’s S/O 15. To facilitate comfort, and

to maintain clean and avoid contamination of
dry clothes. ostomy sit