Diagnosis : Risk for impaired skin integrity related to fluid that came out from the stoma

Goal

: Patient will maintain skin integrity around stoma

Interventions :
1.

Observe stoma when each pouch is change and to note for any irritation, bruises or
rashes around it.

2.

Clean the stoma with water and soap (if it is covered with stools), and then pat dry to
prevent from skin breakdown.

3.

Use a transparent odor-proof drainable pouch for easily monitoring of the stoma
without removing the pouch.

4.

Apply topical medication as prescribed by the doctor to protect the skin from pouch
adhesive.

5.

Support surrounding of the skin when gently removing the pouch to prevent from skin
having irritation because of pulling pouch off.

6.

Consult with ostomy nurse in choosing products that suits for the patients needs and
as well as abilities to handle self-care.

Evaluation : Patient is free from impaired skin integrity.

Diagnosis : Knowledge deficit about stoma related to unfamiliar with information given as
evidenced by inaccurate in performing of ostomy care
Goal

: Patient will verbalized understanding of her condition and correctly perform

ostomy care

Interventions :
1.

Evaluate patients level of understanding to know the ability of the patient to take
responsibility for ostomy care.

2.

Provide patient a pamplets,videos or any learning resources for the patients reference
after discharge for her ostomy care.

3.

Instruct the patient to demonstrate back in ostomy care so that it will reduce the risk
of improper ostomy care and development of complications.

4.

Encourage the patient to increase fluid intake because the she had loss of normal
colon function of conserving water and electrolytes that may lead to dehydration and
constipation.

5.

Advice the patient to reduce food that could be a source of flatus so that she dont
have to empty the pouch more frequently if they are ingested.

6.

Recommend to the patient food that is used to manage constipation such as

celery,bran and raw fruits so it can minimize problems of having constipation.

Evaluation

: Patient had verbalized understanding of her condition and can correctly

performed ostomy care

Diagnosis : Disturbed sleep pattern related to fear of leakage of the pouch and injury of the
stoma as evidenced by patient verbalized not feeling well rested
Goal

: Patient will verbalized feeling well rested

Interventions :
1.

Encourage the patient to empty pouch before retiring on a regular schedule to

minimizes the threat of leakage.

2.

Advice the patient that the stoma will not be injured when sleeping and this will help
the patient to rest better if she know about her stoma and ostomy function.

3.

Encourage the patient to read a book or any bedtime rituals so that she can have a
readiness to sleep and promotes relaxation.

4.

Ask an ostomy nurse or doctor to give reassurance and more information about her
stoma so that the patient will understand more.

5.

Administer sedatives as prescribed by the doctor for bedtime which is may enhance
patient to rest and sleep well especially during the post-operation period.

Evaluation

: Patient verbalized that she rested well.