Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the plan of care?
a. Evaluation and assessment of dietary intake of fiber
b. Evaluation and assessment of patient cleanliness
c. Evaluation and assessment of periostomal skin integrity
d. Evaluation and assessment of the adequacy of the collection device
ANS: C
The nurse should assess the periostomal skin for impairment of integrity. The fecal material is liquid and has a potential for severe skin excoriation from the digestive enzymes.
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