Nursing Nursing

Data Plan / Goal Rationale Evaluation

Diagnosis Interventions

SUBJECTIVE: Risk for Impaired Short-term Independent: Independent: Short-term

Skin Integrity Goal: Goal:
“Kapag hindi related to 1. Assess the 1. Regular
agad nalinis ay colostomy stoma, After 4 hours of peristomal skin assessment of the After 4 hours
nagkakarashes as evidenced by nursing regularly for signs of peristomal skin of nursing
siya. Kaya linis the presence of intervention, the irritation, rashes, or helps to identify intervention,
ako nang linis.” peristomal rashes caregivers will breakdown. any early signs of the caregivers
As verbalized by and potential demonstrate Document the skin breakdown or demonstrated
the mother. discomfort. understanding findings to monitor irritation. understanding
on how to the progression or Documenting on how to
OBJECTIVE: properly improvement. findings allows for properly
manage skin tracking changes manage skin
(+) traces of rashes near the over time and rashes near
rashes in the colostomy site ensuring timely the colostomy
colostomy site and its intervention if site and its
when not cleaned importance to problems worsen. importance to
right away prevent further prevent further
complications. 2. Assess potential 2. Identifying and complications.
allergens or irritants eliminating triggers
in the patient’s can prevent further (GOAL MET)
environment. skin irritation and
promote recovery.

3. Provide proper 3. Proper stoma

stoma care, and care is essential to
teach the patient prevent skin
how to clean and irritation and
care for the stoma infection.
using the correct Educating the
technique and patient empowers
products. them to maintain
skin integrity by
avoiding improper
stoma care
practices that can
contribute to
breakdown.

Dependent: Dependent:

1. Administer 1. Topical
prescribed medications, such
ointments, as corticosteroids
corticosteroids, or or antifungals, can
antifungal creams to help reduce
reduce irritation or inflammation,
treat rashes, as irritation, or fungal
ordered. infections,
improving skin
integrity and
reducing
 discomfort. These
treatments should
only be used as
prescribed by a
healthcare
provider.

2. Pain
2. Administer management
prescribed pain ensures the
management, patient is
including analgesics comfortable during
or topical stoma care and
anesthetics (e.g., daily activities.
lidocaine or Analgesics and
hydrocortisone), as topical anesthetics
needed for skin can reduce the
irritation or discomfort
discomfort. associated with
peristomal skin
irritation or other
pain sources.

Collaborative:
Collaborative:
1. WOCNs have
1. Consult with a expertise in stoma
Wound, Ostomy, care and can offer
and Continence personalized
Nurse (WOCN) for recommendations
specialized advice to prevent skin
on the appropriate breakdown and
products, skin care manage any
routines, and existing skin
techniques. issues.
Collaboration
ensures that the
patient receives
the most effective
care and products
tailored to their
needs.

2. A dermatologist
2. Consult a can help diagnose
dermatologist if the and treat any skin
rash or irritation conditions that
persists or worsens may not be related
despite proper care. to the colostomy
but are
contributing to skin
breakdown. They
can also prescribe
more advanced
 treatments for skin
irritations or fungal
infections.

3. Emotional and
3. Refer to a social psychological
worker or support support is crucial
groups to provide for patients
emotional support, adjusting to life
especially if the with a colostomy.
patient struggles A social worker or
with body image or support group can
adjusting to life with offer coping
a colostomy. strategies and a
network of people
who understand
the challenges,
which may reduce
anxiety and
improve overall
well-being.

HEALTH
HEALTH TEACHING:
TEACHING:
1. Gentle
1. Educate on cleansing prevents
gentle cleansing further irritation
techniques using and maintains skin
mild, fragrance-free barrier function,
soap and lukewarm reducing the risk
water. of infection.

2. Reducing
2. Teach the patient friction and
and family about irritation helps
avoiding scratching minimize
and wearing loose- discomfort and the
fitting clothing. risk of secondary
infections.

3. Early
3. Educate on signs identification of
of secondary infection allows for
infection and when prompt treatment,
to seek medical reducing
attention. complications and
promoting skin
integrity.
1.

Data Nursing Plan / Goal Nursing Rationale Evaluation

 Intervention
Diagnosis
s

SUBJECTIVE: Ineffective Long-term Goal: Independent: Independent: Long-term Goal:

Health
“Minsan nga eh Maintenance After 3 days of 1. Assess 1. Assessing After 3 days of
pinapakain na namin r/t inadequate nursing Mother’s the mother's nursing
nung mga bawal sa understandin intervention, the Knowledge and current intervention, the
kanya don sa G6PD g of the mother and other Address understanding mother and other
niya. Parang wala dietary caregivers: Misconceptions. allows the caregivers:
naman nangyayari management nurse to tailor
sa kanya kaya baka of G6PD - Will follow the teaching to - did not follow
magpa-second deficiency, as dietary her specific dietary
opinion na lang din evidence by guidelines needs, guidelines
kami.” As verbalized the mother’s without feeding addressing without feeding
by the mother. continued the child misconceptions the child
feeding of prohibited and reinforcing prohibited
OBJECTIVE: prohibited foods. accurate foods.
foods. - will verbalize information. - have
(-) immediate signs the rationale This ensures verbalized the
of hemolytic behind dietary the mother rationale
episodes, such as restrictions, grasps the behind dietary
jaundice, fatigue, showing she importance of restrictions, but
pallor, or dark- has dietary did not show
colored urine, internalized management. she has
despite consuming the necessary internalized
the prohibited foods. information. 2. Promote the 2. A food diary the necessary
- will no longer Use of a Food helps the information.
Recent lab results, feed foods that Diary even after mother track - still fed foods
such as a complete are discharge. what foods are that are
blood count contraindicate being contraindicate
(CBC) or reticulocyte d and will seek consumed and d and will seek
count, may advice when provides a tool advice when
show normal unsure. for identifying unsure.
hemoglobin any potential (GOAL NOT MET)
levels, normal red adverse
blood cell (RBC) reactions. It can
count, and no signs also serve as a
of hemolysis (e.g., valuable record
normal bilirubin to discuss with
levels, absence of the healthcare
Heinz bodies on a provider during
blood smear). follow-up visits.

OBSERVATIONS 3. Encourage 3. Empowering

FROM THE Self-Advocacy the mother to
MOTHER: and Open seek
Communication clarification
 The mother is with Healthcare when needed
giving her child Providers. ensures she
foods that are has access to
prohibited for those accurate
with G6PD information and
deficiency (e.g., fava helps reduce
beans, certain anxiety about
medications, or managing her
foods with artificial child’s
colors). condition. It
also reinforces
 The mother the importance
reports no of collaboration
observable with healthcare
symptoms (e.g., professionals.
jaundice, dark urine,
fatigue) after 4. Written
consuming these 4. Provide materials can
foods. Written serve as a
Educational reliable
 The mother may Materials. reference for
not fully understand the mother.
the potential for This allows her
delayed or to review the
subclinical hemolytic information at
reactions. her own pace
and consult it
whenever she
needs
clarification,
helping
reinforce the
teaching.

5. This allows
5. Encourage the nurse to
open-ended gauge the
questions and mother's
discussions to current
assess the knowledge and
mother's address any
understanding. misconceptions,
ensuring clarity
and reinforcing
important
concepts about
managing
G6PD
deficiency.

Dependent:
Dependent:
1. Folic acid is
1. Administer often prescribed
any prescribed to support red
medications or blood cell
supplements that production in
support G6PD children with
management G6PD
(e.g., folic acid, if deficiency.
ordered). Following the
healthcare
provider’s
orders ensures
the child has
adequate
support for
maintaining
healthy blood
cells.

2. Consult the 2. The

healthcare healthcare
provider to provider can
adjust any provide medical
treatment plan if advice or
the mother modifications to
expresses the treatment
concerns about plan if
dietary necessary,
adherence or the ensuring the
child’s health. child’s safety
and addressing
the mother’s
concerns about
dietary
management.

Collaborative: Collaborative:

1. Refer to a 1. A dietitian
dietitian for a can provide
detailed specialized
nutritional knowledge on
assessment and how to balance
tailored meal the child’s
planning. nutritional
needs while
adhering to
G6PD
restrictions,
ensuring the
mother is
equipped to
prepare safe
and nutritious
meals.

2. Consult with a 2. A pediatric

pediatric hematologist
hematologist for can offer expert
further education advice on the
on G6PD child’s condition
deficiency and and how to
long-term avoid triggering
management. foods. They can
help clarify any
questions the
mother may
have and
provide ongoing
support.

3. Reinforce the 3. Continuous

role of the support from
Healthcare healthcare
Team. professionals
provides the
mother with the
resources and
confidence she
needs to
manage her
child’s
condition,
helping to
prevent
mistakes and
ensure optimal
care.

HEALTH HEALTH
TEACHING: TEACHING:

1. Educating on 1. G6PD
Prohibited deficiency can
Foods. cause red blood
cells to break
down
(hemolysis)
when the child
consumes
specific foods
or substances.
Educating the
mother on
which foods to
avoid helps
prevent
hemolytic
episodes and
ensures the
child’s safety.

2. Explaining the
Risks of 2. G6PD
Hemolysis. deficiency may
 cause
a delayed
reaction to
certain foods,
making it
important for
the mother to
understand the
risks and
monitor for
symptoms of
hemolysis that
could appear
hours or days
later.
3. Teach the
importance of 3. Consistency
consistency in in avoiding
diet. harmful foods is
key to
preventing
complications
related to G6PD
deficiency. This
ensures the
child’s health is
maintained and
reduces the risk
of hemolytic
episodes.

Data Nursing Plan / Goal Nursing Rationale Evaluation

Diagnosis Intervention
 s

SUBJECTIVE: Risk for Long-term Goal: Independent: Independent: Long-term Goal:

Ineffective
“Kaya lang naman Coping related After 6 days of 1. Create an 1. A supportive After 6 days of
kami nagpa-admit to the emotional nursing environment that environment nursing
ngayon ay dahil and physical intervention, the is calm, can help reduce intervention, the
isasara na raw changes patient and family reassuring, and feelings of fear patient and family
yung colostomy associated with will express supportive for or anxiety. It expressed
kaya sana the colostomy understanding of the child and also provides a understanding of
magkaigi na ang closure, as the upcoming family, ensuring space where the colostomy
anak ko evidenced by colostomy closure, that they feel the family feels closure,
pagkatapos the upcoming demonstrate safe and cared comfortable demonstrated
sarahan.” As transition from improved coping for. expressing their improved coping
verbalized by the stoma to normal strategies, and concerns, which strategies, and
mother. bowel function verbalize reduced is essential for verbalized reduced
and the anxiety regarding emotional anxiety regarding
potential the transition to coping. the transition to
OBJECTIVE: difficulty normal bowel normal bowel
adapting to the function during 2. Encourage the 2. Maintaining function during
Stable V/S: change. hospitalization (pre- child to maintain familiar routines hospitalization (pre-
op and post-op). normal activities helps the child op and post-op).
BP – 90/60 (e.g., feel more in
T – 35.7 schoolwork, control and less (GOAL MET)
PR – 122 play) as much as overwhelmed
RR – 28 possible, by the changes
SpO2 - 98 adjusting only as associated with
needed for surgery. It also
(-) no normal physical promotes
bowel movement limitations or resilience and
recorded as per comfort. coping by
last shift allowing the
child to
continue
engaging in
regular
activities.

3. Teach the 3. Distraction

child and family techniques can
distraction help reduce
techniques, such anxiety and
as listening to stress by
music, watching focusing the
a favorite show, child’s attention
or reading away from the
books, to help surgery and
manage anxiety associated
leading up to the fears. These
surgery. techniques
promote
relaxation and
coping, which
can enhance
 emotional well-
being.

4. Encourage 4. Encouraging
Open expression the child and
of concerns. family to
express fears
and concerns
allows the
nurse to
address them
directly.
Validating
emotions and
providing
reassurance
supports coping
and reduces
feelings of
helplessness or
anxiety.

5. Involve the 5. Involving the

child (age- family in
appropriate) and decision-
family in making helps
decisions related them feel more
to the child’s in control and
care plan, empowered,
including post- which can
operative improve coping.
expectations and It also promotes
recovery goals. a sense of
partnership with
the healthcare
team, reducing
anxiety about
the unknown
aspects of the
surgery.

Dependent: Dependent:

1. Administer 1. Pain
Pain Relief as management is
Ordered. essential for
promoting
comfort and
recovery,
especially after
major surgery.
Minimizing pain
helps improve
 the child’s
ability to adjust
physically and
emotionally to
the closure of
the colostomy.

2. Coordinate 2. Ensuring that

Post-Operative clear, concise
Care post-operative
Instructions. instructions are
provided to the
family helps
them
understand how
to care for the
child post-
surgery. This
reduces anxiety
and empowers
the family to
take an active
role in the
child’s recovery.

Collaborative: Collaborative:

1. Refer to a 1. A
Pediatric psychologist or
Psychologist or counselor can
Counselor. help both the
child and family
process the
emotional
challenges of
the surgery and
body image
changes.
Professional
emotional
support can
improve coping
and help the
family adjust
more
effectively.

2. Consult with a 2. A dietitian

Dietitian for Post- can offer
Surgical specific advice
Nutritional on how to
Guidance. manage diet
and nutrition
 after the
colostomy
closure. This
ensures the
child’s dietary
needs are met,
promotes
healthy bowel
function, and
alleviates
concerns about
how to handle
the transition to
normal bowel
function.
3. Ensure 3. Regular
Follow-Up follow-up
Appointments appointments
with Healthcare ensure any
Providers. complications
or concerns
post-surgery
are identified
early. Ongoing
care reduces
stress and
ensures the
child and family
feel supported
throughout the
recovery
process.
HEALTH
TEACHING: HEALTH
TEACHING:
1. Provide
education on 1. Educating
Colostomy the family and
Closure and child about the
Post-Surgery procedure,
Expectations. recovery, and
changes in
bowel function
helps reduce
uncertainty and
anxiety.
Understanding
the process
allows for better
emotional
preparedness
and adaptation
to the changes.
2. Gradually 2. Gradual
educate the child exposure to
and family about post-operative
what to expect expectations
after the surgery, helps the child
starting with and family
basic information mentally
and increasing prepare for the
as the surgery changes. This
date progressive
approaches. approach can
reduce feelings
of being
overwhelmed
and foster a
sense of control
over the
situation.

3. Educate the 3. Preparing the

family about family in
post-operative advance
ensures they
care routines,
feel confident in
including how to caring for the
manage the child after the
child’s recovery surgery. This
at home, even reduces anxiety
before discharge by eliminating
from the uncertainty
about post-
hospital.
operative care
and promotes
smoother
adaptation to
the changes.