Questions and Answers Already Passed
A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is
functioning. After removing the pouch, which of the following should the nurse do first?
Measure the stroma
Cover the stroma with gauze
Remove the backing on the skin barrier
Cleanse the stoma and the peristomal skin ✔✔Cleanse the stoma and the peristomal skin
To facilitate the nurse's assessment of the stoma and the peristomal skin, the nurse must remove
any effluent adhering to the area.
A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at
home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the
patient to
Apply hydrocortisone cream to the skin when changing the appliance
, Empty the pouch when it is no more than half full
Wash the peristomal skin frequently with deodorizing soap and water
Choose a time shortly after a meal for replacing the pouch ✔✔Empty the pouch when it is no
more than half full
Waiting until the pouch is more than half full increases the risk of leakage. Ileostomy effluent is
irritating to peristomal skin, so patients should replace the pouch when it is one third to one half
full.
Patients should avoid the use of soap, especially oil or lotion based soaps. They leave a residue
that can interfere with pouch adhesion and increase the risk of leakage. They should cleanse the
skin and warm tap water. For times when soap is essential and if their provider allows it, they
should only use a mild, pH balanced soap.
A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is
scheduled for a creation of a double barrel colostomy in the sigmoid colon. Which of the
following instructions should the nurse include in the teaching?