PHINMA University of Pangasinan

College of Health Sciences

NURSING CARE PLAN

Patient’s Initials: H. Kruz
Age & Gender: 39, Male
Birthdate: September 23, 1984
Address: dagupan City, Pangasinan
Chief Complaint: Abdominal pain
Admitting Diagnosis: Possible perforation
Date of Confinement: January 5, 2023
Name of the Student Nurse: CORPUZ, LORELYN S.
Level/Block/Group: LEVEL 3, BLOCK 3
Clinical Instructor/s: Ma’am Belinda S. De Vera, RN, MAN
Date: January 11, 2023

ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

NURSING ANALYSIS
INDEPENDENT INDEPENDENT
SUBJECTIVE DATA: SHORT-TERM GOALS After several nursing
An ileostomy is an opening Evaluate the patient’s These factors affect the interventions, the
“Hindi ko pa alam kung paano ko constructed in the terminal After several nursing emotional, cognitive, and patient’s ability to master patient will be able to
papalitan at linisan ito, baka ileum to treat regional and interventions, the physical capabilities. care-tasks and willingness gain confidence in self-
masugatan ko ang sarili ko at ulcerative colitis and to patient will be able to to assume responsibility for care as an ostomate.
maimpeksyon ito,” as verbalized gain confidence in self- ostomy care.
divert intestinal contents
by the patient. care as an ostomate.  The patient was
in colon cancer, polyps,
Include written, picture Provides references for able to ask
OBJECTIVE DATA: and trauma. It is usually  The patient will
done when the entire (photo, video, Internet) obtaining support, questions
ask questions learning resources. equipment, and additional regarding the
Patient has ileostomy. colon, rectum, and anus regarding the information after discharge ostomy care.
must be removed, in which ostomy care. to support patient efforts  The patient
The ostomy is red in color. case the ileostomy is  The patient will for independence in self- verbalized his
permanent. A temporary verbalize his care.
The surrounding skin appears therapeutic needs
ileostomy is done to therapeutic needs
normal and no presence of regarding with regarding with
provide complete bowel Review anatomy, Provides knowledge base
abrasion or crusts. ostomy care. ostomy care.
rest in conditions such as physiology, and from which patient can
 The patient will make informed choices,  The patient was
chronic colitis and in some implications of surgical
The ostomy bag has loose to correctly perform and offers an opportunity to able to correctly
trauma cases. intervention. Discuss perform
liquid effluent; green in color. necessary clarify misconceptions
future expectations, necessary
A colostomy is a diversion procedures and regarding an individual
including anticipated procedures and
explain the situation.
of the effluent of the colon changes in the character explain the
rationale for each
and may be temporary or of effluent. rationale for each
of it.
permanent. Ascending, of it.
transverse, and sigmoid Instruct patient/SO in
Vital Signs colostomies may be
performed. Transverse LONG-TERM GOALS stomal care. Allot time for Promotes positive After the whole period
T = 37.0 C colostomy is usually return demonstrations management and reduces of hospitalization, the
PR = 79 bpm temporary. A sigmoid After the whole period and provide positive the risk of improper ostomy patient will be
RR = 16 bpm of hospitalization, the feedback for efforts. care and development of independent doing
colostomy is the most
BP = 110/80 mmHg patient will be complications. self-care activities.
common permanent independent doing self-
stoma, usually performed Recommend increased
NURSING DIAGNOSIS care activities. fluid intake during warm Loss of normal colon  The patient
for cancer treatment. verbalized
weather months. function of conserving
 The patient will water and electrolytes can understanding of
Deficient knowledge related to verbalize lead to dehydration and condition/disease
unfamiliarity with ostomy care and understanding of constipation. process,
changing as evidenced by “Hindi condition/disease Talk about the possibility prognosis, and
ko pa alam kung paano ko process, of sleep disturbance, “Homecoming depression” potential
papalitan at linisan ito, baka prognosis, and anorexia, loss of interest may occur, lasting for complications.
masugatan ko ang sarili ko at potential months after surgery,
in usual activities.  The patient
maimpeksyon ito,” as verbalized complications. requiring patience and
by the patient.  The patient will initiated lifestyle
support and ongoing
initiate lifestyle evaluation as the patient changes.
changes. adjusts to living with a  The patient
 The patient will stoma. demonstrated
demonstrate behaviors to
Investigate reports of promote positive
behaviors to
burning, itching, or Indicative of effluent
self-regard.
promote positive leakage with peristomal
blistering around stoma.
self-regard. irritation, or
possibly Candida infection,
requiring intervention.
DEPENDENT
DEPENDENT
Administer medications
and feeding as ordered Medications and feedings
by the physician. should be administered to
the patient to maintain
balance nutrition and
promotes comfort and
recovery from the surgery.

INTERDEPENDENT
INTERDEPENDENT
Teach the family on how This will also help for the
to give assistance to the
 patient to cope up with his
patient when changing situation now that he has
their ostomy bag and to an ostomy to take care off.
also help in assessing
the ostomy because it
may be hard for the
patient to see it clearly.