一位胃造口滲漏導致潮濕相關皮膚損傷病人之護理經驗

Nursing Experience With a Patient With Gastrostomy Leakage Resulting in Moisture-Associated Skin Damage

10.6224/JN.63.5.127

許美玉(Mei-Yu Hsu)；徐小惠(Hsiao-Hui Hsu)；呂基燕(Ji-Yan Lyu)

胃造口 ； 合併症 ； 滲漏 ； 潮濕相關皮膚損傷 ； 護理經驗 ； gastrostomy ； complication ； leakage ； moisture-associated skin damage ； nursing experience

護理雜誌

63卷5期（2016 / 10 / 01）

127 - 134

繁體中文

滲漏是胃造口常見合併症之一，因暴露於潮濕與化學性刺激的環境，易發生潮濕相關皮膚損傷，嚴重影響生活品質。本文旨在描述一位因胃造口滲漏導致潮濕相關皮膚損傷個案護理經驗。2015年7月29日至2015年8月20日護理期間評估發現：胃造口大量滲漏，致使個案皮膚廣泛性糜爛、潰瘍、瘜肉、表淺感染；同時面臨困難造口照護，令個案身心俱疲。經由筆者多次與醫護進行跨團隊溝通與討論，改變傳統管路及傷口護理方式，以實證文獻為基礎，提供胃造口與潮濕相關皮膚損傷照護策略。在團隊努力下，成功避免皮膚接觸胃內容物，提高個案舒適度；控制滲漏量與皮膚感染，維持體液與電解質平衡，以使皮膚損傷得以痊癒。建議未來醫護人員面對胃造口滲漏病人，應及早提供皮膚保護計畫、確認與矯正滲漏因子，收集滲漏液以及正確固定管路，以降低對病人生活品質之衝擊。同時亦提供病人管路與皮膚照護教育，以預防日後合併症再發生。

Leakage is a common complication of gastrostomy. Exposure of the skin surrounding the gastrostomy tube to moisture or chemical irritants may cause moisture-associated skin damage (MASD) and seriously affect the patient's quality of life. This case study describes a nursing experience with gastrostomy leakage that resulted in MASD. An assessment conducted from July 29, 2015 to August 20, 2015 revealed that heavy gastronomy leakage had caused extensive skin erosion, ulceration, hyperplasia, and superficial infection. Simultaneously, the patient was required to conduct complex stoma care, which resulted in physical and psychological exhaustion. Changes in traditional tube and wound care were discussed on multiple occasions with an interdisciplinary healthcare team. Based on the evidence- based literature, we provide gastrostomy and MASD management strategies. Through team collaboration, we prevented gastric contents from contacting the patient's skin directly, improved patient comfort, controlled effluent and skin infections, maintained fluid and electrolyte balances, and accelerated the healing of the damaged skin. We recommend that healthcare professionals caring for patients with gastrostomy leakage be provided with early skin protection programs to learn the standard methods for identifying and correcting leakage factors, containing effluent, and adequately stabilizing the gastrostomy tube in order to reduce the impact on the patient's quality of life. In addition, patient education on tube and skin care should be provided to prevent the reoccurrence of complications.

1. National Nurses Nutrition Group. (2015). Good practice guideline-Changing of a balloon gastrostomy tube (BGT) into the stomach for adults and children. Retrieved from http://www.nnng.org.uk/wp-content/uploads/2015/07/Good_practice_balloon_gastrostomies_Final_July_12.pdf
2. DeLegge, M. H. (2015b). Gastrostomy tubes: Complications and their management. In J. R. Saltzman, T. O. Lipman, & A. C. Travis (Eds.), UpToDate. Retrieved from http://www.uptodate.com/contents/gastrostomy-tubes-complicationsand-their-management
3. DeLegge, M. H. (2015a). Gastrostomy tubes: Placement and routine care. In J. R. Saltzman, T. O. Lipman, & A. C. Travis (Eds.), UpToDate. Retrieved from http://www.uptodate.com/contents/gastrostomy-tubes-placement-and-routinecare
4. Agency for Clinical Innovation,Gastroenterological Nurses College of Australia(2014).A clinician's guide: Caring for people with gastrostomy tubes and device.
5. Beitz, J.,Gerlach, M.,Ginsburg, P.,Ho, M.,McCann, E.,Schafer, V.,Turnbull, G.(2010).Content validation of a standardized algorithm for ostomy care.Ostomy Wound Management,56(10),22-38.
6. Blumenstein, I.,Shastri, Y. M.,Stein, J.(2014).Gastroenteric tube feeding: Techniques, problems and solutions.World Journal of Gastroenterology,20(26),8505-8524.
7. Bryant, R. A.(Ed.),Nix, D. P.(Ed.)(2012).Acute and chronic wounds: Current management concepts.St. Louis, MO:Mosby.
8. Collins, K.,Gaffney, L.,Tan, J.,Roberts, S.,Nyulasi, I.(2013).,未出版
9. Colwell, J. C.,Ratliff, C. R.,Goldberg, M.,Baharestani, M. M.,Bliss, D. Z.,Gray, M.,Black, J. M.(2011).MASD part 3: Peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis: A consensus.Journal of Wound, Ostomy and Continence Nursing,38(5),541-553.
10. Gomes, C. A. R., Jr.,Andriolo, R. B.,Bennett, C.,Lustosa, S. A. S.,Matos, D.,Waisberg, D. R.,Waisberg, J.(2015).Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances.Cochrane Database of Systematic Reviews,5,CD008096.
11. Gray, M.,Black, J. M.,Baharestani, M. M.,Bliss, D. Z.,Colwell, J. C.,Goldberg, M.,Ratliff, C. R.(2011).Moisture-associated skin damage: Overview and pathophysiology.Journal of Wound, Ostomy and Continence Nursing,38(3),233-241.
12. Itkin, M.,DeLegge, M. H.,Fang, J. C.,McClave, S. A.,Kundu, S.,d'Othee, B. J.,Cardella, J. F.(2011).Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE).Gastroenterology,141(2),742-765.
13. Locher, J. L.,Bonner, J. A.,Carroll, W. R.,Caudell, J. J.,Kilgore, M. L.,Ritchie, C. S.,Allison, J. J.(2012).Gastrostomy tube placement and use in patients with head and neck cancer.Head & Neck,34(3),422-428.
14. Rahnemai-Azar, A. A.,Rahnemaiazar, A. A.,Naghshizadian, R.,Kurtz, A.,Farkas, D. T.(2014).Percutaneous endoscopic gastrostomy: Indications, technique, complications and management.World Journal of Gastroenterology,20(24),7739-7751.
15. 李美慧(2006)。台北市=Taipei City, Taiwan, ROC，國立陽明大學臨床護理研究所=Institute of Clinical Nursing, National Yang-Ming University。

1. 葉沛縈、陳筱萍、吳靜怡(2018)。胰腎同時移植術後傷口周圍潮濕相關性皮膚炎之護理經驗。護理雜誌，65(2)，109-118。