Registered Nurses' Association of Ontario

History and Physical

A pre-operative history and physical assessment provides information that will serve as baseline data for developing a comprehensive plan of care. A consensus of expert opinion supports that this assessment should include:

  • demographic data including age and gender
  • diagnosis and client’s presenting problem
  • history of client’s problem
  • prognosis: curative or palliative
  • surgical plan including type of ostomy (ileostomy, urostomy, colostomy); and expected duration (temporary, permanent)
  • clients’ and families’ interpretation of prospective surgery
  • psychological preparedness of client and family
  • clients’ and families’ interpretation of life with an ostomy
  • social history including occupation, interpersonal relationships, sexuality, cultural and spiritual practices and financial considerations related to ostomy supplies
  • physical and cognitive challenges and environmental/living conditions that could impact learning and self-care
  • functional assessment focusing on cognitive and psychomotor skills needed for ostomy self-management, including identification of patients with specific physical needs such as impaired dexterity, sight, or hearing
  • abdominal assessment for stoma site marking

Modified from Borwell, (1996)

Chronic Disease
Ostomy Care and Management
Point of Care Resources