Problem Identified: Impaired skin integrity Nursing Diagnoses: Impaired skin integrity r/t stasis of secretions or drainage secondary

to colostomy. Cause Analysis: Presence of colostomy increases contact of fecal matter around stoma which may result to damage on the surrounding tissues (Doenges, M.E. Nursing Care Plan, 8 ed. p. 338)
Cues Subjective: Dili man siya sakit answered by the patient when asked about his colostomy stump on LLQ of his abdomen. Objective: Colostomy bag in place on LLQ of abdomen with dark red output. Reddish stoma with reddish surrounding skin. Encourage side-lying position with head elevated. Avoid prolonged sitting. Promotes drainage from perineal wound/drains, reducing risk of pooling. Prolonged sitting increases perineal pressure, reducing circulation to wound, and may delay healing. Collaborative: Assisted in irrigating the wound as indicated, using antibiotic solution. May be required to treat preoperative inflammation, infection, or intraoperative contamination. LTO: Within 3 days of nursing interventions, the patient will not develop further symptoms of infection such as pain, swelling and unusual drainage. Large amounts of serous drainage require that Changed dressings as needed. dressings be changed frequently to reduce skin irritation and potential for infection. STO: Within 8 hours of nursing interventions, the patients colostomy bag will be kept clean and drained as indicated. Objectives Independent: Observed wounds, noting characteristics of drainage. Postoperative hemorrhage is most likely to occur during the first 48 hours, whereas infection may develop at any time. Depending on type of wound closure, complete healing may take 6 to 8 months. LTO: After 3 days of nursing interventions, no manifestations of development of further tissue impairment or infection were noted. Nursing Interventions Rationale STO: Within 8 hours of shift, the patients colostomy bag was kept clean and was drained as indicated. Evaluation
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Reference: Doenges, M.E. (2008). Nursing Care Plan, 8th ed. p. 338