Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

What is the first step in pouching a fistula?

1. Apply paste to the wound edges

2. Cleanse the skin

3. Use adhesive tape

4. Measure the fistula size

The correct answer is: Cleanse the skin

Cleansing the skin is essential as the first step in pouching a fistula because it prepares the skin for proper adhesion of the pouching system. This step involves removing any debris, exudate, or contaminants that may be present around the fistula site. Proper skin cleansing helps reduce the risk of infection and enhances the effectiveness of the adhesive used in the pouching system by promoting better adherence to clean, dry skin. After cleansing, other steps such as measuring the fistula size or applying paste to the wound edges would follow to ensure the pouch fits well and creates an effective barrier. However, without adequately cleansing the skin first, the subsequent actions may not be as successful in achieving a secure and hygienic pouching of the fistula.