During assessment of the patient with an ileostomy, the nurse discovers that the opening of the pouch is about 5/8” inch larger than the stoma. This patient is at increased risk for which adverse outcome?

Skin breakdown around the stoma . The goal of sizing the pouch opening is to make it nearly the size of the stoma, perhaps 1/8” inch larger than the outer edge of the stoma. If too much skin is exposed around the stoma—but covered by the pouch—the skin will become excessively moist and irritated. Feces may collect between the stoma and the seal, further irritating the skin. A pouch opening that is too large should not interfere with blood flow to the stoma, is no more likely to fall off, and can form the same seal as a smaller pouch opening.

During assessment of the patient with an ileostomy, the nurse dis...

Category: Physiological Adaptation
Difficulty: 8

Topics: Gastrointestinal Assessment Elimination Tissue Integrity

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