# Situation: A 60-year-old man had an abdominoperineal resection with a permanent descending colostomy for rectal cancer 7 days ago. The stoma is pink and moist, and the colostomy is functioning. His wife will help him at home. The nurse begins discharge teaching. Two weeks after discharge, his wife reports that the skin around the stoma is red. The stoma now measures 30 mm across; at discharge it measured 34 mm, and she still cuts the skin barrier using the 36-mm template given at discharge. Which instruction should the nurse give?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629754  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 60-year-old man had an abdominoperineal resection with a permanent descending colostomy for rectal cancer 7 days ago. The stoma is pink and moist, and the colostomy is functioning. His wife will help him at home. The nurse begins discharge teaching.

Two weeks after discharge, his wife reports that the skin around the stoma is red. The stoma now measures 30 mm across; at discharge it measured 34 mm, and she still cuts the skin barrier using the 36-mm template given at discharge. Which instruction should the nurse give?

## 보기

1. Keep the 36-mm opening and apply a skin lotion before the barrier
2. Cut the barrier opening to exactly 30 mm so no skin is exposed
3. Re-measure the stoma and cut the opening to about 32 mm **✔ 정답**
4. Widen the opening to 40 mm so the red skin can air out

**정답: 3**

## 해설

A new stoma shrinks as postoperative swelling subsides, so it is re-measured about weekly for 6 to 8 weeks. The barrier opening should be only about 1.5 to 3 mm larger than the stoma; a 36-mm opening around a 30-mm stoma leaves a ring of skin exposed to stool, causing the redness. For a 30-mm stoma, an opening of about 32 mm is correct.

## 심화 해설

The redness around the stoma two weeks after discharge is a classic sign of irritant contact dermatitis from effluent leaking onto peristomal skin. The wife is still using the 36-mm template given at discharge, but the stoma has shrunk from 34 mm to 30 mm as postoperative edema resolved. This leaves a 6-mm ring of exposed skin around the stoma—well beyond the acceptable gap—allowing stool and digestive enzymes to contact and break down the skin.

A new stoma shrinks as postoperative swelling subsides, so it must be re-measured about weekly for the first 6 to 8 weeks. The barrier opening should be only 1.5 to 3 mm larger than the stoma itself. For a 30-mm stoma, the correct opening is approximately 32 mm. This snug fit protects the peristomal skin from effluent while avoiding pressure or cutting injury to the stoma tissue.

| Opening size | Gap around stoma | Result |
| --- | --- | --- |
| 36 mm (current, from discharge template) | 6 mm exposed skin | Effluent contacts skin, causing erythema and irritation |
| 30 mm (exact stoma size) | 0 mm | Risk of cutting or constricting the stoma as it moves or swells slightly |
| 32 mm (correct) | 2 mm (within 1.5–3 mm range) | Protects skin while allowing safe clearance |

Watch out! Option 1 is unsafe because applying lotion under the barrier interferes with adhesion and does not solve the exposure problem. Option 2 is too tight—cutting exactly to 30 mm risks trauma to the stoma from friction or pressure. Option 4 would worsen the problem by exposing even more skin to effluent.

Peristomal skin irritation is one of the most common complications for ostomates, and the primary prevention is a correctly fitted pouching system. Clinical studies show that erythema can develop rapidly when skin barriers do not fit properly, and that patient and family education on measuring and cutting the barrier is essential to maintaining skin integrity. The wife should be taught to re-measure the stoma at its base with a measuring guide, cut the barrier to 32 mm, and reassess weekly as the stoma continues to stabilize over the first two months postoperatively.

## 임상 시나리오

Postoperative Stoma MeasurementPreventing peristomal skin breakdown after discharge
A new stoma shrinks as postoperative edema resolves, so re-measure it weekly for the first 6 to 8 weeks.

Cut the skin barrier opening only 1.5 to 3 mm larger than the stoma. For a 30-mm stoma, use about a 32-mm opening.

CautionDo not cut the opening exactly to stoma size or apply lotion under the barrier; both can cause stoma trauma or loss of adhesion and worsen skin irritation.

## 핵심 개념

- **Peristomal skin** — Skin immediately surrounding a stoma; prone to irritation from contact with effluent.
- **Skin barrier** — Adhesive wafer placed over peristomal skin to protect it and secure the pouch.
- **Irritant contact dermatitis** — Skin inflammation caused by direct chemical irritation, such as stool or digestive enzymes on peristomal skin.
- **Stoma shrinkage** — Normal reduction in stoma size during the first 6-8 weeks as postoperative edema resolves.
- **Abdominoperineal resection** — Surgical removal of the rectum and anus with creation of a permanent colostomy.

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