The nurse is teaching the patient how to size the skin barrier around the stoma. Which instruc-tions does the nurse include?
a. Use the measurement guide for a proper fit.
b. Extend the skin barrier to cover the inci-sional area.
c. Make a wick from toilet tissue before changing the skin barrier.
d. Trim the skin barrier to fit slightly over the stoma margin.
A
The nurse instructs a patient to measure the stoma with the measurement template so the stoma will have enough room to fit and to ensure that there is no excessive pressure on the stoma to impair its blood flow. The nurse instructs the patient to avoid covering the incisional area because it is unnecessary and can interfere with healing if the barrier covers a new surgical incision. Toilet tissue wicks can leave residue on the stoma. If a wick is made to absorb drainage, it should be made using gauze. The nurse avoids extending the skin barrier over the stoma to maintain adequate blood flow to the tissue.
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