The nurse assesses the client's incontinent urinary diversion and observes reddened peristomal skin. Which is the best nursing intervention to promote skin integrity?
1. Apply an antiseptic ointment.
2. Keep the peristomal area dry.
3. Change the pouching equipment.
4. Fit stoma with a tight skin barrier.
2
2. The best nursing intervention for reddened peristomal skin is to keep the area clean and dry; for a incontinent urinary diversion, this means that the nurse measures a skin barrier to fit within - to -inch of the stoma to prevent fluid from collecting.
1. Reddened skin does not necessarily indicate infection, so the antiseptic ointment can be contraindicated.
3. Changing the pouching equipment is a reasonable nursing response after the nurse determines that keeping the area dry is ineffective.
4. The nurse fits the skin barrier properly for the stoma; making the skin barrier tight can cause impaired blood flow to the stoma.
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