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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed body STG: 1.) Establish rapport >To gain client’s trust and STG:
“Gaano katagal pa image r/t In 2-3 hours of cooperation After 2-3 hours of nursing
ba ito sa tiyan ko? biophysical nursing 2.) Monitor and record interventions the pt. will
Ang pangit.” As colostomy interventions the pt. vital signs >To obtain baseline data be able to:
verbalized by the pt. will be able to:
3.) Assess general >To determine interventions 1. “Kailangan ko ito para
Objective: 1. Verbalize condition sa mailabas ng maayos
needed by the client
*c presence of understanding of ang mga dumi ng katawan
stoma @ RLQ body image changes ko” as werbalized by the
*dry and intact 4.) Assess perception of >The extent of response is pt.
midline incision LTG: change in structure or more related to the value of
*appears withdrawn In 3 days the pt. will function of body part importance the pt places on LTG:
*verbalize feeling be able to: the part/function than actual After 3 days the pt. will be
about colostomy value able to:
1. Demonstrate and
enhance body image 1. Pt. is able to look at the
and self-esteem 5.) Assess perceived >To determined how the pt stoma as well as talk about
impact of change on act to changes and care for the colostomy
activities of daily living bag
social behaviour and
personal responsibilities

6.) Evaluate level of pt’s >It may indicate acceptance


knowledge of and anxiety or non-acceptance of
r/t situation; observe situation
emotional changes
>To evaluate need for
7.) Note signs of grieving/ counselling and/or
indicators of severe medications
depression

>May influence how


8.) Observe interaction of
client with SO’s individual deals with what
happened

9.) Establish therapeutic >Distortions in body image


nurse-client relationship may be unconsciously
conveying an attitude of reinforced by family
caring and developing trust
members and/ or secondary
acknowledge the
gain issues may interfere
individual as someone
worthwhile with the progress

10.) Encourage >Provides opportunities for


verbalizations of and role listening to concerns and
play anticipated conflicts questions

11.) Encourage the client >To enhance handling of


to use denial without potential situations
participating