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NURSING PROBLEM: Disturbed Body Image related to presence of stoma, loss of control of bowel elimination AEB verbalization of

negative feelings about body, fear of rejection/reaction of others.

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLANNING INTERVENTION RATIONALE

EXPECTED

OUTCOME

Subjective

Cues

Tinatago ko

yung supot,

nakakahiya kase

kapag makita

ng ibang tao

may dumi ko,

as verbalized by

the patient

Objective

Cues

o Presence of

descending

Disturbed Body

Image related to

presence of

stoma; loss of

control of bowel

elimination AEB

verbalization of

negative feelings

about body, fear

of

rejection/reaction

of others.

The client withostomy faces

alterations in

self-concept and

body image. This

body image is

the attitude a

person has about

the

actual/perceived

structure

or function of all

or part of the

body. This

attitude is

dynamic and is

altered through

interaction withother people and

situations as an

important

part of ones self

concept. Body

image

disturbance can

have profound

After 1 hour of

nursing

intervention, the

client will:

Verbalize

acceptanceof self in

situation,

incorporatin

g change

into self-

concept

without

negating

self-esteem.

Demonstrate

acceptance

by touching

the stoma

and

o Assess

perception of

change in

structure or

function of

body part

o

Explain to

patient the

importance of

the procedureto aid in

recovery.

o Encourage

o The extent

of

response

is more

related to

the value

of

importanc

e the

patient

places on

the part.

o

Providing

informatio

n to the

patientcan

somehow

enhance

well being

and

outlook.

o Patient

After 1 hour of

nursing

intervention the

client shall have

o Verbalized

acceptance of

self in situation

AEB

expression of

feelings about

stoma.

o Demonstrated

acceptance of

stoma AEB

touching and

participating

in self care.

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o Advise SO to

provide

support and

enhance

interaction

with patient.

o Plan/schedule

care activities

with patient.

normal

peristalsis.

o Distortions

in body

image

may be

unconscio

usly

reinforced

by the

family.

o Promotes

sense of

control

and gives

message

that

patient

can

handle

situation,

enhancing

self-

concept.

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colostomy at

left

abdominal

area

o Generalized

weakness

noted

o Itchiness on

the

surrounding

of the stoma

o Improvised

colostomy

bag and

garter as a

holder.

peristomal

area with bare

hands.

o

Demontrate

peristomal

area cleaning

using clean

water/ NSS

before a new

pouch isapplied.

o Educate the

patient that

the pouch

should be

changed every

4-5 days when

leakage

occurs.

o Teach the

patient to

empty pouch

risk for

infection.

o

To provide

proper

ostomy care

and prevent

complicatio

ns

o To increase

patients

awareness

on proper

ostomy care.

o The client

should

demonstrate

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when it is

about half full

including

proper

emptying.

o Consult with

certified

wound ostomyif persistence

of rashes is

present.

the ability to

empty and

change the

pouch

independen

tly before

being

discharge

o May be

helpful in

choosingproducrs for

healing

rehabilitatio

n