The nurse notes that the skin around the stoma of a client with an ileostomy is partially denuded. What should the nurse do?
1. Keep the appliance off
2. Apply skin barrier paste
3. Apply Stomahesive powder
4. Increase the size of the stoma opening on the barrier
3
Rationale 1: Keeping the appliance off can increase skin irritation.
Rationale 2: Skin barrier paste is applied to the opening on the pouch.
Rationale 3: Stomahesive powder should be applied to denuded skin only.
Rationale 4: Increasing the size of the stoma opening will encourage leakage and cause more skin breakdown.
Global Rationale: Stomahesive powder should be applied to denuded skin only. Keeping the appliance off can increase skin irritation. Skin barrier paste is applied to the opening on the pouch. Increasing the size of the stoma opening will encourage leakage and cause more skin breakdown.
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