The nurse has identified the goals of "intact skin integrity" and "intact stoma integrity" for a patient with a colostomy
Which evaluation parameters are best suited for these goals? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The stoma is pink and moist.
2. No excoriation is noted on skin surrounding the stoma.
3. The patient shows understanding of importance of preventing fecal leakage.
4. The patient demonstrates ability to apply the collecting appliance properly.
5. The stomal area is free of pain.
1,2
Rationale 1: The stoma should be pink and moist.
Rationale 2: The skin surrounding the stoma should be intact, with no excoriation.
Rationale 3: Teaching about the prevention of fecal leakage is an important part of the care of this patient but does not address the goals provided.
Rationale 4: The patient must know how to apply collection appliances, but this does not address the stated goals.
Rationale 5: The stomal area should not be painful, but this statement does not address the stated goals.
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