Nursing diagnosis: Risk for Impaired Skin Integrity
Risk factors may include
Absence of sphincter at stoma
Character and flow of effluent and flatus from stoma
Reaction to product or chemicals; improper fitting or care of appliance/skin
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain skin integrity around stoma.
Identify individual risk factors.
Demonstrate behaviors or techniques to promote healing and/or prevent skin breakdown.
Nursing intervention with rationale:
1. Inspect stoma and peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), and rashes.
Rationale: Monitors healing process and effectiveness of appliances. Identifies areas of concern and need for further evaluation and intervention. Early identification of stomal ischemia or infection (from changes in normal bowel flora) provides for timely interventions to prevent serious complications. Stoma should be red and moist. Ulcerated areas on stoma may be from a pouch opening that is too small or a faceplate that cuts into stoma. In clients with an ileostomy, the effluent is rich in enzymes, increasing the likelihood of skin irritation. In clients with a colostomy, skin care is not as great a concern because the enzymes are no longer present in the effluent.
2. Clean with warm water and pat dry. Use soap only if area is covered with sticky stool. If paste has collected on the skin, let it dry, and then peel it off.
Rationale: Maintaining a clean and dry area helps prevent skin breakdown, and increases adherence of appliances.
3. Measure stoma periodically—at least weekly for first 6 weeks, then once a month for 6 months. Measure both width and length of stoma.
Rationale: As postoperative edema resolves, the stoma shrinks and the size of the appliance must be altered to ensure proper fit, so that effluent is collected as it flows from the ostomy and contact with the skin is prevented.
4. Verify that the opening on the adhesive backing of the pouch is no more than 1/16 to 1/8 inch (2–3 mm) larger than the base of the stoma, with adequate adhesive barrier to apply pouch.
Rationale: Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area prevents the skin barrier wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.
5. Use a transparent, odor-proof drainable pouch.
Rationale: A transparent appliance during the first 4 to 6 weeks allows easy observation of stoma without necessity of removing pouch and irritating skin.
6. Apply appropriate skin barrier—hydrocolloid wafer, karaya gum, extended-wear skin barrier, or similar products.
Rationale: Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Sigmoid colostomy may not require an appliance if elimination is regulated through irrigation.
7. Empty, rinse, and cleanse ostomy pouch on a routine basis, using appropriate equipment.
Rationale: Frequent changes of the adhesive barrier wafer are irritating to the skin and should be avoided. Emptying and rinsing the pouch with the proper solution removes bacteria and odor-causing stool and flatus.
8. Support surrounding skin when gently removing appliance. Apply adhesive removers as indicated, and then wash thoroughly.
Rationale: Prevents tissue irritation and destruction associated with “pulling” pouch off.
9. Investigate reports of burning, itching, or blistering around stoma.
Rationale: Indicative of effluent leakage with peristomal irritation, or possibly Candida infection, requiring intervention.
1o. Evaluate adhesive product and appliance fit on ongoing basis.
Rationale: Provides opportunity for problem solving. Determines need for further intervention.