ATI Skills Module 3.0: Ostomy Care

A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? A. Measure the stoma. B. Cover the stoma with gauze. C. Remove the backing on the skin barrier D. Cleanse the stoma and the peristomal skin.

A. Cleanse the stoma and the peristomal skin. Rationale: First action nurse should take is to remove any effluent adhering to the stoma & peristomal skin to facilitate assessment of area

A nurse is obtaining health history from a patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The patient reports that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? A. Consume foods that are low in fiber content. B. Take an ounce of mineral oil twice a day. C. Add buttermilk and cranberry juice to the diet. D. Increase water intake to 3 to 3.5 L per day.

A. Consume foods that are low in fiber content. Rationale: The nurse should recommend that pt consume foods low in fiber to help thicken stool. Ex: rice, noodles, white bread, & cheese

A nurse is teaching a patient who has bladder cancer about urinary diversion options. The nurse should inform the patient that which of the following options will allow them to have some control over urinary elimination? A. Kock's pouch B. Ileal conduit C. Cutaneous ureterostomy D. Nephrostomy

A. Kock's pouch Rationale: A Kock's pouch is a continent ileal bladder conduit that does not require an external drainage collection device because pt self-catheterizes every 2-4 hrs to remove urine. This device will allow pt to have some control over urinary elimination

A nurse is teaching a patient who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? A. Apply hydrocortisone cream to the skin when changing the appliance. B. Empty the pouch when it is less than half full. C. Wash the peristomal skin frequently with deodorizing soap and water . D. Choose a time shortly after a meal for replacing the pouch.

B. Empty the pouch when it is less than half full. Rationale: Nurse should instruct pt to empty pouch when it is between 1/3 to 1/2 full because waiting to empty pouch until it is more than 1/2 full increases risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin.

A nurse is reinforcing teaching with a patient who has colon cancer & is scheduled for a procedure to remove their entire large intestine & rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? A. Cecostomy B. Loop colostomy C. Ileostomy D. Descending colostomy

C. Ileostomy Rationale: After removing the entire large intestine & rectum, provider will create an ileostomy to divert feces from the small intestine to the abdominal surface & into an ostomy pouch.

A nurse is providing preoperative teaching for a patient who is scheduled for creation of a sigmoid colostomy. Which of the following info should the nurse include in the teaching? A. Expect the effluent from the sigmoid colostomy to be loose and continuous. B. Use irrigation to help establish a regular bowel pattern. C. Change the stoma's appliance every other day. D. Expect effluent from the newly created stoma within 24 hr after surgery.

B. Use irrigation to help establish a regular bowel pattern. Rationale: Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance.

A nurse is reinforcing teaching w/ a pt about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? A. Lift up on both sides of the skin barrier simultaneously. B. Release one corner of the barrier and pull it quickly over the stoma. C. Push the skin away from the barrier while removing it. D. Gently roll the barrier end-over-end across the stoma.

C. Push the skin away from the barrier while removing it. Rationale: If pt is experiencing pain w/ initial release of barrier, nurse should suggest removing barrier by starting in one corner & gently pulling it across the stoma while pushing skin away from barrier. This technique can help prevent skin stripping.

A nurse is teaching a patient about extended-wear skin barriers. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? A. Use an oil-based lotion on the peristomal area. B. Apply the skin barrier while the skin is slightly moist. C. Leave the residue from the previous appliance on the skin. D. Press gently around the barrier for 30 seconds to 1 min.

D. Press gently around the barrier for 30 seconds to 1 min. Rationale: The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.