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

Question

Quizplus · Accepted Answer

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.

A Nurse Is Pouching an Ostomy on a Patient with an Ileostomy