The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago. When changing the client's one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and erythematous

Question

The client does not empty the pouch until it is completely full because it hurts so much to remove the skin barrier. Which action by the nurse is the priority?

1. Apply a two-piece ostomy appliance.
2. Treat the damaged skin and replace the one-piece pouch.
3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance in a few days.
4. Call the health care provider to report the damaged skin.

Answer 1

Correct Answer: 1

The client who requires emptying of the pouch one or more times per day will benefit from a drainable pouch. However, when the client lacks dexterity, he will benefit from a drainable two-piece pouch, allowing the pouch to be removed to empty, instead of a drainable pouch. A one-piece pouch needing to be changed daily requires the client to remove both the pouch and the skin barrier, which could be the cause of the trauma. Allowing the pouch to fill completely before changing can lead to leakage, which will also contribute to the skin damage. Because the client has an ileostomy, leaving the appliance off is not an option, because the ostomy will drain continuously. There is no need to call the health care provider, because the nurse can provide skin care without an order.