REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING

NURSING CARE PLAN

NAME OF STUDENT: Detablan, Aimee Kaileen S. YEAR/GROUP: 3-BN CONCEPT: Colostomy AREA: General Ward DATE: 25 September 2021
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Risk for Impaired Impaired skin integrity
Subjective Skin Integrity is a nursing diagnosis, Long Term Objective
Cues defined as alteration in
“Masakit siya nurse” the epidermis and/or
verbalized by the dermis. The skin is
patient when asked subject to injury from a
about his colostomy variety of external and
of his abdomen internal factors.
Friction, shear,
moisture, pressure,
Objective and trauma are all
Cues causes of skin
-Reddish stoma breakdown. These
with reddish factors can work
surrounding skin together or alone to Short Term Objective
damage and injure
Vital signs: skin. Immobility, poor
BP: 130/80 mmHg nutrition, incontinence,
P: 79 beats per min medications,
R: 20 bpm hydration, impaired
T: 36.6 C mental status, and loss
O2 Sat: 100% of sensation are other
culprits in skin
breakdown.

Referrence:
https://medical-
dictionary.thefreedictio
nary.com/impaired+ski
NAME OF PATIENT:_________________________________ AGE:_______________
CLINICAL IMPRESSION/DIAGNOSIS:______________________________ CHIEF COMPLAINT:_________________________________
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING

n+integrity#:~:text=imp
aired%20skin
%20integrity%20a
%20nursing,of
%20external%20and
%20internal
%20factors.

Reference:

NAME OF PATIENT:_________________________________ AGE:_______________

CLINICAL IMPRESSION/DIAGNOSIS:______________________________ CHIEF COMPLAINT:_________________________________