A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
A.
“Use povidone-iodine to clean around the stoma.”
B.
“Cut the opening of the pouch / of an inch larger than the stoma.”
C.
“Empty the ostomy pouch when it becomes one-third full of contents.”
D.
“Place a piece of gauze over the stoma while changing the pouch.”
E.
“Expect the stoma to turn a purple-blue color as it heals.”
The correct answer and Explanation is :
The correct instructions for ostomy care teaching are:
C. “Empty the ostomy pouch when it becomes one-third full of contents.”
D. “Place a piece of gauze over the stoma while changing the pouch.”
Explanation:
- Empty the Ostomy Pouch When It Becomes One-Third Full: It is essential to empty the ostomy pouch before it becomes too full to prevent leakage and skin irritation. Typically, it is recommended to empty the pouch when it is about one-third full. This helps in maintaining the effectiveness of the pouch seal and ensures that the stoma site remains clean and dry.
- Place a Piece of Gauze Over the Stoma While Changing the Pouch: Placing a piece of gauze over the stoma while changing the pouch helps to protect the stoma from accidental contact with the contents of the pouch and keeps the area clean. It also prevents the stoma from coming into contact with any adhesive remover or cleaning solution that could irritate it.
Incorrect Instructions:
A. “Use povidone-iodine to clean around the stoma.”: Povidone-iodine (Betadine) is too harsh for cleaning around the stoma. It can cause skin irritation and is generally not recommended. Instead, a mild soap and water or a stoma-specific cleanser should be used.
B. “Cut the opening of the pouch one inch larger than the stoma.”: The opening should be cut to fit the stoma as closely as possible without touching it. A common guideline is to leave a small margin (usually about 1/8 to 1/4 inch) around the stoma to prevent irritation. Cutting the opening too large can lead to leakage and skin irritation.
E. “Expect the stoma to turn a purple-blue color as it heals.”: A healthy stoma should be pink to red in color. A purple-blue color could indicate poor blood flow or ischemia, which requires medical evaluation. It is important to monitor the stoma’s color and report any changes to a healthcare provider.
These guidelines are crucial for maintaining proper ostomy care and ensuring the comfort and health of the client.