ASSESSMEN NURSING CLIENT OUTCOME CRITERIA NURSING RATIONALE ACTUAL EVALUATION

T DIAGNOSI GOAL INTERVENTIONS

S

Disturbed Client will After 3 days of nursing 1. Ascertain 1. Provides After 3 days of nursing
Body demonstrat interventions: whether information interventions:
Image e and support and about  Client
 Client will counseling patient’s/SO’s verbalized
related to verbalize
verbalize were level of acceptance of
altered acceptance
acceptance of initiated knowledge self in situation,
body of self in self in situation, when the and anxiety incorporating
structure. situation. incorporating possibility about an change into
change into and/or individual self-concept
self-concept necessity of situation. without
without ostomy was 2. Helps the negating self-
negating self- first patient realize esteem.
esteem. discussed. that feelings  Client
 Client will 2. Encourage are not demonstrated
demonstrate patient/SO unusual and beginning
beginning to verbalize that feeling acceptance by
acceptance by feelings guilty about viewing/touchi
viewing/touchi regarding them is not ng stoma and
ng stoma and the ostomy. necessary or participating in
participating in Acknowledg helpful. self-care.
self-care. e normality Patient needs  Client
 Client will of feelings to recognize verbalized
verbalize of anger, feelings before feelings about
feelings about depression, they can be stoma/illness;
stoma/illness; and grief dealt with begin to deal
begin to deal over a loss. effectively. constructively
constructively Discuss daily 3. Patient may with situation.
with situation. “ups and find it easier to
downs” that accept or deal
can occur. with an
3. Review the ostomy done
reason for to correct
surgery and chronic or
future long-term
expectations disease than
. for traumatic
4. Note injury, even if
behaviors of ostomy is only
withdrawal temporary.
increased Also, patient
dependency who will be
, undergoing a
manipulatio second
n, or non- procedure (to
involvement convert
in care. ostomy to a
5. Provide continent or
opportunitie anal reservoir)
s for may possibly
patient/SO encounter less
to view and severe self-
touch image
stoma, using problems
the moment because body
to point out function
positive eventually will
signs of be “more
healing, normal.”
normal 4. Suggestive of
appearance, problems in
and so forth. adjustment
Remind the that may
patient that require further
it will take evaluation and
 time to more
adjust, both extensive
physically therapy.
and 5. Although
emotionally. integration of
6. Provide an stoma into
opportunity body image
for the can take
patient to months or
deal with even years,
ostomy looking at the
through stoma and
participation hearing
in self-care. comments
7. Plan/schedu (made in a
le care normal,
activities matter-of-fact
with the manner) can
patient. help the
8. Maintain a patient with
positive this
approach acceptance.
during care Touching
activities, stoma
avoiding reassures
expressions patient/SO
of disdain or that it is not
revulsion. fragile and
Do not take that slight
angry movements of
expressions stoma reflect
of the normal
patient and peristalsis.
SO 6. Independence
 personally. in self-care
9. Ascertain helps improve
patient’s self-
desire to confidence
visit with a and
person with acceptance of
an ostomy. the situation.
Make 7. Promotes a
arrangemen sense of
ts for a visit, control and
if desired. gives a
message that
patient can
handle the
situation,
enhancing self-
concept.
8. Assists patient
and SO to
accept body
changes and
feel all right
about self.
Anger is most
often directed
at the
situation and
lack of control
individual has
over what has
happened
(powerlessnes
s), not with the
individual
 caregiver.
9. A person who
is living with
an ostomy can
be a good
support
system/role
model. Helps
reinforce
teaching
(shared
experiences)
and facilitates
acceptance of
change as the
patient
realizes “life
does go on”
and can be
relatively
normal.