ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
S: O Risk for Contaminati Short Term: Independent: Short Term:
infection on of a
related to wound 1. Observe and -With the onset of
After 8 hours After 8 hours
presence of surface with report signs of infection the
O: of effective of effective
colostomy microorganis infection such as immune system is
nursing nursing
> post site at the m thus this redness, warmth, activated and signs
interventions of infection appear. interventions,
transverse loop right quadrant colonization discharge, and
, patient will patient states
colostomy of abdomen has a be able to: increased body
temperature. symptoms of
complete infection of
>colostomy site new cells for -Preventive skin
a. Free from 2. Assess skin for which to be
at right side of oxygen and assessment
the abdomen symptoms of color, moisture, aware and
nutrition and infection texture, and protocol, including demonstrates
because turgor (elasticity). documentation, appropriate
their by- Keep accurate, assists in the hygienic
b. States
products can ongoing prevention of skin measures
symptoms of
interfere with documentation of breakdown. Intact such as hand
infection of
a healthy changes. skin is nature's first washing, oral
which to be
surface aware line of defense care, and
condition against colostomy
that leads to microorganisms care.
infection. c.Demonstra entering the body
tes (Kovach, 1995).
Reference: appropriate -GOAL
hygienic -Immune function is PARTIALLY
Brunner & 3. Encourage a MET.
measures balanced diet, affected by protein
Suddarth’s such as intake (especially
Medical- emphasizing
hand proteins to feed arginine); the
Surgical washing, balance between
Nursing 13th the immune
oral care, system. omega-6 and
Edition. and omega-3 fatty acid
colostomy intake; and
care adequate amounts
of vitamins A, C,
and E and the
minerals zinc and
iron. A deficiency of
 these nutrients puts
the client at an
increased risk of
infection (Lehmann,
1991).

4.Encourage
adequate rest to -Chronic disease
bolster the and physical and
immune system. emotional stress
increase the client's
need for rest (Potter,
Perry, 1993).

-to assess if there is

5.Reviewenviron a need of avoidance
mentalfactors or modification of
environment to
reduce incidence of
infection.

Dependent: -to determine

effectiveness of
6.Administer and therapy and if there
instruct is a presence of side
precautions effect.
regarding
medication
regimen and note
clients response.