Asked by Beauty Shoot on May 22, 2024

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A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most\bold{most}most appropriate?

A) Changing the skin barrier portion of the ostomy pouch daily
B) Emptying the pouch if it is more than one-third to one-half full
C) Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive
D) Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma

Ostomy Pouch

A medical device used to collect waste from a surgically created opening in the body, such as from the intestine or urinary tract.

Skin Barrier

The protective outermost layer of the skin that defends against environmental threats and prevents the loss of moisture.

Stoma

Artificially created opening between a body cavity and the surface of the body (e.g., a colostomy formed from a portion of the colon pulled through the abdominal wall).

  • Determine suitable nursing actions for patients experiencing issues with bowel elimination.
  • Apply efficient communication techniques to instruct patients on bowel elimination, ostomy maintenance, and dietary guidance.
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CA
Chum-Chum AndradeMay 25, 2024
Final Answer :
B
Explanation :
Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may disrupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.