ATI Skills Module 3.0: Ostomy Care 2024/2024

ATI Skills Module 3.0: Ostomy Care 2024/2024 A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? A. Measure the stoma. B. Cover the stoma with gauze. C. Remove the backing on the skin barrier D. Cleanse the stoma and the peristomal skin. - answer-A. Cleanse the stoma and the peristomal skin. Rationale: First action nurse should take is to remove any effluent adhering to the stoma & peristomal skin to facilitate assessment of area A nurse is teaching a patient about extended-wear skin barriers. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? A. Use an oil-based lotion on the peristomal area. B. Apply the skin barrier while the skin is slightly moist. C. Leave the residue from the previous appliance on the skin. D. Press gently around the barrier for 30 seconds to 1 min. - answer-D. Press gently around the barrier for 30 seconds to 1 min. Rationale: The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.