Care Plan for Ileostomy

Category / Primary Body System

• Gastrointestinal System

Problem

• Patient is at risk for complications due to ileostomy.

Goal

1. Patient will have no skin breakdown for 90 days.
2. Ileostomy will remain functional for 90 days.

Plan/Approach

1. Skin Care and Monitoring

   • Monitor for skin irritations and breakdown around the stoma site
   • Maintain a clean and dry area around the ileostomy

2. Ileostomy Function Monitoring

   • Monitor ileostomy drainage for consistency, color, and amount
   • Ensure ileostomy appliance is functioning properly and fitting securely

3. Nutritional Management

   • Provide nutritional evaluation and guidance as needed
   • Encourage adequate fluid intake to prevent dehydration

4. Patient Education and Support

   • Educate the patient on proper ileostomy care techniques
   • Encourage verbalization of concerns or issues related to ileostomy care
   • Provide resources and support for ongoing ileostomy management

Rationale

1. Skin Care and Monitoring

   • Regular monitoring and maintaining cleanliness around the stoma site prevent skin irritation and breakdown, reducing the risk of infection.

2. Ileostomy Function Monitoring

   • Monitoring the ileostomy output ensures it remains functional and helps detect potential complications early.
   • Proper appliance fitting prevents leaks and skin irritation, promoting comfort and function.

3. Nutritional Management

   • Nutritional evaluation ensures the patient’s diet supports overall health and ileostomy function.
   • Adequate fluid intake is crucial to prevent dehydration, a common risk for ileostomy patients.

4. Patient Education and Support

   • Educating the patient on ileostomy care empowers them to manage their condition effectively, reducing anxiety and promoting self-care.
   • Providing emotional support helps the patient adjust to life with an ileostomy, improving quality of life.

Actions

1. Skin Care and Monitoring

   • Assess the skin around the stoma daily for any signs of redness, irritation, or breakdown.
   • Clean the area around the stoma with mild soap and water, ensuring it is dry before applying a new appliance.
   • Use skin barriers and protective products as recommended to prevent irritation.

2. Ileostomy Function Monitoring

   • Check ileostomy output at least every shift, noting the color, consistency, and volume.
   • Ensure the ileostomy appliance is securely attached and functioning properly, replacing it as needed.
   • Educate the patient on signs of appliance malfunction and when to seek assistance.

3. Nutritional Management

   • Schedule regular consultations with a dietitian to tailor the patient’s diet to their specific needs.
   • Encourage the patient to drink at least 8-10 glasses of water daily, unless contraindicated.
   • Provide education on foods that may affect ileostomy function, such as high-fiber or gas-producing foods.

4. Patient Education and Support

   • Teach the patient and caregivers proper techniques for changing and maintaining the ileostomy appliance.
   • Provide written materials and demonstrations on ileostomy care.
   • Offer regular check-ins to address any concerns or difficulties the patient may have with their ileostomy care.
   • Encourage participation in support groups or counseling for additional emotional support.