The nurse evaluates nursing care of the client's ureterostomy. Which nursing intervention should the nurse eliminate or improve to prevent client complications?
1. Empty the pouch when it is at least half full.
2. Assess peristomal area for edema and pain.
3. Apply a skin barrier within -inch of stoma.
4. Place a gauze wick in stoma for pouch change.
1
1. The nurse needs to increase the rate of pouch emptying when the ureterostomy pouch is one third to one half full to avoid excessive tension on the pouch seal, pre-vent leaking, and prevent potential trauma to the peristomal skin.
2. The nurse assesses the peristomal area for edema and pain to gather information about the stoma and cue the nurse to the potential for infection and the need for fur-ther investigation.
3. The nurse applies the skin barrier to within - to -inch of the stoma to prevent pe-ristomal skin breakdown.
4. The nurse places a gauze wick in the stoma to collect draining urine during the pouch change because ureterostomies drain urine continuously.
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