Skin integrity disorder: Skin disorder around the stoma (risk state)

Skin integrity disorder: Skin disorder around the stoma (risk state)

<Definition>
Skin integration disorders include mechanical factors (compression, slippage, rubbing, attachment / detachment of adhesive, etc.), chemical factors (stool, urine, exudate, etc.), infection, allergies, drug treatment, radiation therapy, aging, etc. This is a condition in which the skin is damaged and the protective defense function is disrupted.

<Nursing care plan>

Target
Heals skin disorders around the stoma
Does not cause skin damage around the stoma (risk condition)

Observation plan
1. Vital signs
2. Age and gender
3. Weight, weight change, BMI
4. Nutrition and water intake
5. Contents and course of treatment
6. Stoma and surrounding skin condition (redness, erosion, epidermal peeling, pain)
7. Presence or absence of complications (hernia, stenosis, etc.)
8. Volume and properties of stool
9. Presence / absence and degree of stool leakage
10. Is the equipment correct?
11. Presence or absence of skin trouble due to adhesive
12. How to keep clean
13. How to replace the stoma
14. Stoma replacement procedure
15. Knowledge of stoma
16. Accept and mental state about stoma
17. Utilization of social support

Care plan
1. Evaluate the skin around the stoma (ABCD-Stoma) once () times.
2. Select the appropriate orthotic device based on the characteristics of the abdomen and stoma
3. Keep a record of skin condition and replacement method so that the same care can be performed.
4. When replacing the orthotic device, check the degree of dissolution of the skin protectant and consider the frequency of replacement.
5. When removing the orthotic device, use an adhesive remover to gently remove it while pressing the skin.
6. When cleaning, use a mild cleaning agent
7. When cleaning, wrap it in foam and pat it.
8. Control defecation
9. Provide mental assistance if the stoma is unacceptable
10. Introducing social support

Education plan
1. Explain how to observe the skin around the stoma
2. Explain the properties and volume of stool appropriate for the stoma
3. Explain the types of orthotics and skin protectants and how to use them.
4. Explain how to remove the equipment
5. Explain the need to keep the skin around the stoma clean and how to clean it
6. Explain that if a stool leaks, replace it quickly.
7. For diarrheal stools, explain that the stools in the pouch should be treated as soon as possible.


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