# Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions. On postoperative day 6, the nurse evaluates the plan of care for preventing peristomal skin damage. Which finding BEST shows that this goal is being met?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions.

On postoperative day 6, the nurse evaluates the plan of care for preventing peristomal skin damage. Which finding BEST shows that this goal is being met?

## 보기

1. The pouch was emptied four times during the shift
2. The skin around the stoma is intact without redness **✔ 정답**
3. The skin barrier has been replaced every day
4. The client looks at the stoma during pouch changes

**정답: 2**

## 해설

A goal is evaluated by an outcome in the client, not by the care activities performed. Intact peristomal skin without redness directly shows that skin damage is being prevented. Emptying the pouch and changing the barrier are interventions, and looking at the stoma relates to a body image goal.

## 심화 해설

Understanding the Question

The question asks which finding best shows that the goal of preventing peristomal skin damage is being met. The key word is best, which means you must select the option that most directly reflects the client outcome, not merely the care delivered.

A goal is evaluated by an outcome in the client, not by the care activities performed. This principle is central to the nursing process. Interventions such as emptying a pouch or changing a barrier are actions the nurse takes. They may be appropriate, but they do not prove that the skin is actually healthy. The only option that directly measures the condition of the peristomal skin is the finding that the skin is intact and without redness.

Why Option 2 Is Correct

Peristomal skin damage most commonly presents as irritant contact dermatitis caused by exposure to effluent from the stoma [3]. When the pouching system fits properly and the skin barrier remains intact, the peristomal skin stays dry and free from chemical irritation. Therefore, intact peristomal skin without redness is the direct, observable client outcome that confirms the skin has not been damaged. This aligns with the WOCN Society’s emphasis on assessing and promoting peristomal skin health as a primary goal of ostomy care [2].

Why the Other Options Are Incorrect

| Option | Category | Why It Does Not Best Show the Goal Is Met |
| --- | --- | --- |
| 1. The pouch was emptied four times during the shift | Nursing intervention | Emptying the pouch prevents leakage and reduces skin exposure, but it is an action. The frequency of emptying does not prove the skin is currently undamaged. A pouch could be emptied frequently yet still leak, causing skin breakdown. |
| 3. The skin barrier has been replaced every day | Nursing intervention | Routine barrier replacement is a preventive measure. However, changing the barrier too frequently can itself traumatize the peristomal skin. The outcome of interest is the skin condition, not how often the barrier was changed. |
| 4. The client looks at the stoma during pouch changes | Psychosocial outcome | This finding relates to body image adjustment and acceptance of the stoma, which is a different nursing goal. It does not provide any information about the physical integrity of the peristomal skin. |

Clinical Application and Exam Focus

In ostomy care, peristomal skin complications are among the most common and avoidable problems for patients . The WOCN Society identifies peristomal skin health as a distinct outcome requiring regular assessment [2]. When evaluating a plan of care, you must always ask: “What is the evidence in the client that the problem is resolved or prevented?” For skin integrity, that evidence is visual inspection showing intact, non-erythematous skin.

Watch out! Do not confuse interventions (what the nurse does) with outcomes (what happens to the client). Options 1 and 3 are interventions. Option 4 is an outcome for a different nursing diagnosis.

Key point! The correct answer for any “goal is being met” question must reflect a measurable change in the client’s condition, not the completion of a task. Intact skin without redness is the only option that directly measures the absence of skin damage.References (research sources)

- [2]Peristomal Skin Health: A WOCN Society Consensus Conference.GuidelineRatliff CR, Goldberg M, Jaszarowski K, McNichol L, Pittman J, Gray M (2021) · DOI: 10.1097/WON.0000000000000758

- [3]Intestinal Stomas-Postoperative Stoma Care and Peristomal Skin Complications.Research articleSteinhagen E, Colwell J, Cannon LM (2017) · DOI: 10.1055/s-0037-1598159

## 임상 시나리오

Peristomal Skin Protection: Outcome EvaluationAssess the skin, not just the tasks
A goal is evaluated by a client outcome, not by nursing interventions. The direct evidence that peristomal skin damage is being prevented is intact skin without redness around the stoma.

Peristomal skin breakdown most often results from irritant contact dermatitis due to effluent leakage. A properly fitted skin barrier keeps the area dry and free from chemical irritation.

CautionEmptying the pouch 4 times per shift or changing the barrier daily are interventions—they do not prove the skin is healthy. Routine daily barrier changes may actually cause mechanical trauma.

## 핵심 개념

- **Peristomal skin** — The skin surrounding a stoma; vulnerable to damage from effluent leakage, adhesives, or mechanical trauma.
- **Abdominoperineal resection** — Surgical removal of the rectum and anus with creation of a permanent colostomy, typically for low rectal cancer.
- **Skin barrier** — A protective wafer or seal placed on peristomal skin to attach the pouch and shield skin from stomal output.
- **Client outcome** — A measurable change in the patient's health status used to evaluate whether a nursing goal has been met.
- **Irritant contact dermatitis** — Inflammation of peristomal skin caused by direct chemical irritation from stomal effluent.

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