Difficulty: Medium
Average Score: 95%
Simulated
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct answer
B,C,D
Rationale
Correct Answer: B, C, D
Rationale:
B: Cutting the opening of the pouch 1/8 inch larger than the stoma helps prevent skin irritation and allows for proper fit around the stoma.
C: Emptying the ostomy pouch when it becomes one-third full prevents leakage and skin irritation.
D: Placing a piece of gauze over the stoma while changing the pouch helps protect the stoma and surrounding skin from irritation and trauma during the process.
Summary:
A: Using povidone-iodine can irritate the skin around the stoma and is not recommended for routine ostomy care.
E: A purple-blue color is not a typical sign of healing for a stoma and may indicate complications.
Rationale:
B: Cutting the opening of the pouch 1/8 inch larger than the stoma helps prevent skin irritation and allows for proper fit around the stoma.
C: Emptying the ostomy pouch when it becomes one-third full prevents leakage and skin irritation.
D: Placing a piece of gauze over the stoma while changing the pouch helps protect the stoma and surrounding skin from irritation and trauma during the process.
Summary:
A: Using povidone-iodine can irritate the skin around the stoma and is not recommended for routine ostomy care.
E: A purple-blue color is not a typical sign of healing for a stoma and may indicate complications.