NURSING DIAGNOSIS: Actual/Risk for impaired tissue integrity

related to:
  1. disruption of tissue associated with the surgical procedure;
  2. delayed wound healing associated with factors such as decreased nutritional status and inadequate blood supply to wound area;
  3. irritation of skin associated with:
    1. contact with wound drainage, ileostomy output (effluent is rich in proteolytic enzymes), soap residue and perspiration under the pouch, and/or mucous drainage from the anus (occurs if rectum was left intact)
    2. frequent or improper removal of tape, adhesives, or other substances used to secure pouch to the skin
    3. aggressive cleansing of peristomal area
    4. sensitivity to tape, pouch material, and/or substances used to secure pouch to the skin (e.g. adhesive disk, skin barrier, adhesive spray)
    5. pressure from tubes, appliance belt, and/or pouch drainage valve or clamp.
Desired Outcome
The client will experience normal healing of surgical wounds (see Standardized Postoperative Care Plan, Diagnosis 10, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 10, for measures related to assessment and promotion of wound healing.
Desired Outcome
The client will maintain integrity of peristomal and perianal skin and skin in contact with wound drainage, tape, and tubings as evidenced by:
  1. absence of redness and irritation
  2. no skin breakdown.
Nursing Actions and Selected Purposes/Rationales
  1. Inspect skin areas that are in contact with wound drainage, tape, and tubings for signs of irritation and breakdown.
  2. Assess for signs and symptoms of:
    1. peristomal irritation or breakdown (e.g. redness, inflammation, and/or excoriation of peristomal skin; reports of itching or burning under the pouch seal; inability to keep pouch on)
    2. perianal irritation or breakdown (e.g. redness, inflammation, and/or excoriation of perianal skin; reports of itching or burning in perianal area).
  3. Refer to Standardized Postoperative Care Plan, Diagnosis 10, for measures to prevent and treat irritation and breakdown in areas in contact with wound drainage, tape, and tubings.
  4. Implement measures to prevent peristomal irritation and breakdown:
    1. shave or clip hair from peristomal skin if necessary to help achieve an adequate pouch seal and to reduce irritation when the pouch system is removed
    2. patch test all products that will come in contact with the skin (e.g. sealant, barrier, adhesive, solvent) before initial use; do not use products that cause redness, rash, itching, or burning
    3. change entire pouch system only when necessary (e.g. if pouch seal is leaking, if client reports burning or itching of the peristomal skin, when the stoma size changes); pouch system is usually changed every 3 days in the early postoperative period and then should be able to remain in place for 5-7 days
    4. use a 2-piece pouch system (e.g. faceplate and pouch, wafer with flange and pouch) during the initial postoperative period so that pouch can be removed to assess the stoma without having to remove the adhesive from the skin
    5. perform actions to reduce peristomal irritation during removal of the pouch system:
      1. place drops of warm water or solvent where the pouch system adheres to the skin in order to facilitate removal; allow time for adhesive to loosen before removing pouch system
      2. remove pouch system gently and in direction of hair growth; hold skin adjacent to the skin barrier taut and push down on skin slightly to facilitate separation
    6. perform actions to prevent effluent from coming in contact with the skin when changing the pouch system or pouch:
      1. change the pouch or pouch system when the ileostomy is least active (e.g. upon awakening in the morning, before meals, 2-4 hours after eating, before retiring at night)
      2. place a wick (rolled gauze pad, tampon) on the stoma opening when the pouch system or pouch is off
    7. cleanse peristomal skin thoroughly with mild soap and water, rinse completely, and pat dry; use tepid rather than hot water to prevent burns
    8. apply skin sealant to the clean, dry peristomal skin before applying the skin barrier in order to protect skin from the irritating effect of the adhesive
    9. always use a skin barrier (e.g. Stomahesive) to protect skin from the proteolytic enzymes that are in the effluent
    10. perform actions to prevent effluent from contacting the skin when the pouch system is on:
      1. measure the diameter of the stoma; cut skin barrier the same size as stoma and select a pouch with an opening that is not more than 0.3 cm (1/8 inch) larger than the stoma (it may be necessary to create a pattern to use for cutting barrier and pouch openings if stoma has an irregular shape and cannot be measured using appliance manufacturer's standard measuring guide)
      2. instruct and assist client to remeasure the stoma frequently during the first 6-8 weeks after surgery and to alter size of skin barrier and pouch openings as stomal edema decreases
      3. implement measures to achieve an adequate pouch seal:
        1. avoid use of ointments or lotions on peristomal skin (these can interfere with adequate adhesive bonding)
        2. follow manufacturer's instructions when applying skin products and pouch system
        3. use products such as ostomy paste (e.g. Stomahesive paste) to fill in irregularities around stoma site (e.g. body folds, scars) before applying pouch system
        4. apply firm pressure and remove air pockets when applying pouch system; place client in a supine position to increase tautness of skin surface during application
      4. empty pouch when it is 1/3 full of effluent or inflated with gas (a heavy or inflated pouch can cause the pouch system to separate from the skin)
      5. position pouch so gravity flow facilitates drainage away from stoma and peristomal skin
      6. rinse out bottom of drainable pouch after emptying it and then close pouch clamp securely to prevent leakage
      7. use a drainable pouch, 2-piece pouch system, and/or pouch with release valve if gas is a problem; never puncture or cut the pouch to release gas because effluent can seep out of the opening
    11. if a belted pouch system is used, fasten the belt so that 2 fingers can slip easily between belt and skin to prevent excessive pressure on skin
    12. instruct and assist client to check pouch periodically to ensure that pouch clamp is not placing pressure on the skin.
  5. Implement measures to prevent perianal irritation and breakdown:
    1. keep perianal area clean and dry
    2. instruct client to perform perineal exercises (e.g. relaxing and tightening perineal and gluteal muscles) regularly to increase anal sphincter tone and reduce the risk of mucus leakage
    3. place absorbent pads in client's underwear if needed and change pads when they become damp
    4. apply petroleum-based ointment to perianal area as ordered to protect skin.
  6. If signs and symptoms of peristomal or perianal skin irritation or breakdown occur:
    1. cleanse areas gently with warm water
    2. avoid use of any product that may have caused the irritation or breakdown
    3. perform skin care as ordered or according to hospital procedure (usual care may include exposing affected area to air for 20-30 minutes, applying an antifungal agent or corticosteroid preparation to affected skin, and/or covering all irritated skin with a solid skin barrier)
    4. consult appropriate health care provider (e.g. wound care specialist, ET nurse, physician) if areas of irritation or breakdown do not improve within 48 hours.