The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has the highest priority for the patient?
a. Impaired skin integrity r/t localized skin irritation from liquid stool
b. Social isolation r/t potential leakage of stool from ostomy appliance
c. Knowledge deficit r/t care and maintenance of ostomy appliance
d. Disturbed body image r/t presence of stoma and altered elimination
ANS: A
The highest priority nursing diagnosis for this patient is impaired skin integrity because the liquid stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can lead to bacterial infection and significant discomfort for the patient. In addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing skin breakdown.
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