10 Ileostomy and Colostomy Nursing Care Plans

Risk for Impaired Skin Integrity

Nursing Diagnosis

• Risk for Impaired Skin Integrity

Risk factors may include

• Absence of sphincter at the stoma
• Character/flow of effluent and flatus from the stoma
• Reaction to product/chemicals; improper fitting/care of appliance/skin

Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client will maintain skin integrity around the stoma.
• The client will identify individual risk factors.
• The client will demonstrate behaviors/techniques to promote healing/prevent skin breakdown.

Nursing Assessment and Rationales

1. Inspect the stoma and peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), rashes
Monitors the healing process and effectiveness of appliances and identifies areas of concern, need for further evaluation, and intervention. Early identification of stomal necrosis or ischemia or fungal infection (from changes in normal bowel flora) provides for timely interventions to prevent serious complications. Stoma should be red and moist. Ulcerated areas on the stoma may be from a pouch opening that is too small or a faceplate that cuts into the stoma. In patients with an ileostomy, the effluent is rich in enzymes, increasing the likelihood of skin irritation. In patients with a colostomy, skin care is not as great a concern because the enzymes are no longer present in the effluent.

2. Measure stoma periodically: at least weekly for the first 6 wk, then once a month for 6 mo. Measure both the width and length of the stoma.
As postoperative edema resolves (during the first 6 wk), 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.

3. Investigate reports of burning, itching, or blistering around the stoma.
Indicative of effluent leakage with peristomal irritation, or possibly Candida infection, requiring intervention.

Nursing Interventions and Rationales

1. Clean with warm water and pat dry. Use soap only if the area is covered with a sticky stool. If the paste has collected on the skin, let it dry, then peel it off.
Maintaining a clean and dry area helps prevent skin breakdown.

2. Verify that the opening on the adhesive backing of the pouch is at least 1⁄16 to 1⁄8 in (2–3 mm) larger than the base of the stoma, with adequate adhesiveness left to apply the pouch.
Prevents trauma to the stoma tissue and protects the peristomal skin. An adequate adhesive area prevents the skin barrier wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.

3. Use a transparent, odor-proof drainable pouch.
A transparent appliance during the first 4–6 wk allows easy observation of the stoma without the necessity of removing the pouch/irritating skin.

4. Apply appropriate skin barrier: hydrocolloid wafer, Karaya gun, extended-wear skin barrier, or similar products.
Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of the pouch when necessary. Note: Sigmoid colostomy may not require the use of a skin barrier once stool becomes formed and elimination is regulated through irrigation.

5. Empty, irrigate, and cleanse the ostomy pouch on a routine basis, using appropriate equipment.
Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with the proper solution not only removes bacteria and odor-causing stool and flatus but also deodorizes the pouch.

6. Support surrounding skin when gently removing the appliance. Apply adhesive removers as indicated, then wash thoroughly.
Prevents tissue irritation or destruction associated with “pulling” the pouch off.

7. Evaluate adhesive product and appliance fit on an ongoing basis.
Provides an opportunity for problem-solving. Determines the need for further intervention.

8. Consult with a certified wound, ostomy, and continence nurse.
Helpful in choosing products appropriate for the patient’s particular rehabilitation needs, including the type of ostomy, physical/mental status, abilities to handle self-care, and financial resources.

9. Apply corticosteroid aerosol spray and prescribed antifungal powder as indicated.
Assists in healing if peristomal irritation persists and/or fungal infection develops. Note: These products can have potent side effects and should be used sparingly.