Nursing Documentation of Peristomal Skin Lesions

Background: Peristomal skin and tissue integrity alterations are common following stoma surgery despite advances in stoma care. Accurate, pertinent, and up-to-date documentation of peristomal skin lesions are essential for quality care and patient safety. Nursing records are a foremost source of information for follow-up treatment, statistical and care evaluation purposes. Lack of standardized documentation can lead to inconsistent communication which in turn can lead to lack of clarity about how to manage the child's condition and reduced quality of care. This research is funded by Intermountain Healthcare Nursing Research Fellowship and Sigma Theta Tau International Gamma Rho Chapter Research Grant.

Purpose: This project examined what factors are documented by nurses to describe peristomal skin lesions (e.g., color, size); and the different terms used to describe peristomal skin lesions in children.

Methods: Data were collected through retrospective chart review. Conceptual content analysis and descriptive statistics were used for the analysis.

Results: Finding from peristomal skin lesion documentation were categorized into issues common to paper charting and issues specific to peristomal skin documentation.

Paper charting issues:

• readability, handwriting, misspellings,
• inconsistent location for the charting, and
• use of ambiguous phrases and symbols      

Peristomal skin documentation issues:

• ostomy charted but skin not mentioned
• many ways to say normal
• inconsistences in describing
  • color
  • location
  • size
  • difficult to track healing progress

Implications for Clinical Practice: This study is part of a larger dissertation study examining a standardized peristomal skin assessment tool for use by clinicians and parents. This study illustrates the importance of standardized descriptions of peristomal skin lesions. Consistent descriptions of peristomal lesions provide a way to compare interventions, match interventions with peristomal skin conditions, and assess outcomes across time and between patients. These are crucial steps to developing evidence to support quality care and efficiently manage and prevent peristomal skin lesions.