skin integrity
Instructed patient caregiver when you should call the doctor: Injury to the stoma, bad skin irritation or deep sores (ulcers) a lot of bleeding from the stoma opening or a moderate amount in the pouch that you notice several times when emptying it. Eating beets will cause some red discoloration.
Instructed patient caregiver when you should call the doctor: continuous bleeding where the stoma meets the skin unusual change in your stoma size or color anything unusual going on with your ostomy.
Instructed patient call your provider if: Your stoma is swollen and is more than a 1/2 inch (1 cm) larger than normal.Your stoma is pulling in, below the skin level. Your stoma is bleeding more than normal.
Patient instructed on the importance of drinking 6-8 glasses of water per day. Hydration is important for wound healing, healthy skin, digestion, healthy kidneys, and electrolyte balance. Instructed on the increased risk for dehydration during the summer months.
SN assessed portacath insertion site every visit. SN instructed s/sx to report to SN / MD such as redness, pain, puffiness around port, drainage from insertion site, temperature above 100 degrees, shortness of breath and chest pain. Sn instructed on portacath care and protection of the skin over the port.
SN completed patient cardiovascular and pulmonary assessment. Educated staff on monitoring patient for dizziness, syncope, cardiovascular status, anxiety, and agitation related to medication SEs. Staff to encourage patient to rise slowly to prevent syncope and dizziness. Staff instructed to monitor environmental hazards to prevent falls and injuries in addition to monitoring skin for breakdown due to episodes of bowel and bladder incontinence.
SN instructed patient the following way you can help prevent an infection wash your hands, use soap or an alcohol-based hand rub to clean your hands. Check your skin every day for signs of infection, such as pain, redness, swelling, and oozing. Contact your primary healthcare provider if you see these signs.
Instructed patient Call 911 anytime you think you may need emergency care. For example, call if: You passed out (lost consciousness). You have signs of severe bleeding, such as: A severe headache that is different from past headaches. Vomiting blood or what looks like coffee grounds. Passing maroon or very bloody stools. Call your doctor or nurse call line now or seek immediate medical care if: You have unexpected bleeding, including: Blood in stools or black stools that look like tar. Blood in your urine. Bruises or blood spots under the skin. You feel dizzy or light-headed.
Instructed patient about how help decrease edema and keep it from coming back -Protection. Keep the affected area clean, moisturized and free from injury. Dry, cracked skin is more prone to scrapes, cuts and infection. Always wear protection on your feet if that's where the swelling typically occurs.
Instructed patient DO NOT massage the skin near or on the ulcer. This can cause more damage. DO NOT use donut-shaped or ring-shaped cushions. They reduce blood flow to the area, which may cause sores.