Nursing diagnosis: risk for impaired Skin Integrity
Risk factors may include
Absence of sphincter at stoma (actual) with continuous flow of urine
Character and flow of urine from stoma
Reaction to product or chemicals, improper fitting of appliance or removal of adhesive
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Integrity: Skin and Mucous Membranes
Maintain skin integrity.
Identify individual risk factors.
Demonstrate behaviors and techniques to promote healing and prevent skin breakdown.
Nursing intervention with rationale:
1. Inspect stoma and peristomal skin. Note irritation, bruises, rashes, and status of sutures.
Rationale: Stoma should be pink or reddish, similar to mucous membranes. Color changes may be temporary, but persistent changes may require surgical intervention. Early identification of stomal ischemia or fungal infection provides for timely interventions to prevent skin necrosis.
2. Clean with water and pat dry, or use hair dryer on cool setting.
Rationale: Maintaining a clean and dry peristomal area helps prevent skin breakdown.
3. Touch stoma gently to prevent irritation.
Rationale: Mucosa has good blood supply and bleeds easily with rubbing or trauma.
4. Measure stoma periodically, for example, each appliance change for first 6 weeks, then monthly times six.
Rationale: As postoperative edema resolves, size of appliance must be altered to ensure proper fit so that urine is collected as it flows from the stoma and contact with the skin is prevented.
5. Apply effective sealant barrier, such as Skin Prep or similar product, as recommended by appliance manufacturer.
Rationale: Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Some barriers are designed to be used without skin sealant.
6. Ensure proper opening for adhesive backing of pouch. Using a stoma-measuring guide or ostomy sizer, find the smallest opening that fits over the stoma and does not allow any skin exposure. Cut the barrier to size with adequate adhesive area left to apply pouch.
Rationale: Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area is important to maintain a seal. Note: Too tight a fit may cause stomal edema or stenosis.
7. Use a transparent, odor-proof drainable pouch. Keep gauze square over stoma while cleansing area, and have client cough or strain before applying skin barrier wafer.
Rationale: A transparent appliance during first 4 to 6 weeks allows easy observation of stoma and stents when used, without necessity of removing appliance and irritating skin. Covering stoma prevents urine from wetting the peristomal area during pouch changes. Coughing empties distal portion of conduit, followed by a brief pause in drainage to facilitate application of appliance.
8. Avoid use of karaya-type appliances.
Rationale: Will not protect skin because urine melts karaya.
9. Apply waterproof tape around pouch edges, if desired.
Rationale: Reinforces anchoring to help maintain seal.
10. Connect collecting pouch to continuous bedside drainage system when necessary.
Rationale: May be needed during times when rate of urine formation is increased, such as while intravenous (IV) fluids are administered. Weight of the urine can cause pouch to pull loose and leak when pouch becomes more than half full.