Nursing Application for Bowel Elimination

Identify the assessment findings that require immediate follow-up.

*lost 15 pounds *fatigue *"I don't know how to take care of this thing." *decrease in appetite *"I don't know what to eat."​

Review the scenario below. Select the findings that require immediate follow up?

*not making eye contact. *"I don't want to see her. I don't want to see anyone." *"Just look at me. I have a bag hanging off of me with stuff coming out. I hate it. I don't want anyone to ever see it." *No. I don't want to do any of that.

Which of the following outcomes is appropriate for a patient with a knowledge deficit about ostomy care?

Client will demonstrate applying a pouching system.

Intestine that is opened and pulled outside the abdominal wall for the purpose of defecation is called a 1._____________.

Stoma

The nurse is doing client teaching with John regarding stoma self-care. Which finding would the nurse teach John to seek immediate attention?​

The stoma is black.

John stated, "My friend is having a pool party and I am unsure how to deal with it." Which of the following statements from the nurse displays effective therapeutic communication?

"Let's talk about this."​

Select the nursing interventions used in implementing the plan. Select all that apply.

*Consult a specialist in ostomy care. *Encourage the client to express feelings about body changes. *Encourage the client in self-care with a step-by-step approach to ostomy care.

Which of the following are factors that affect bowel elimination? Select all that apply.

*Diet *Age *History of Crohn's disease *Family history *Physical activity

Click on the diagnoses that are related to a client with an ostomy. ​

*Self-care deficit ​*Sexual dysfunction *Knowledge deficit *Impaired skin integrity ​*Disturbed body image​

1. John verbalized acceptance of self with an ostomy 2. John demonstrated acceptance by viewing or touching stoma and participating in self-care 3. John verbalized feelings about ostomy and social situations

1. "It's not that bad and I am getting used to it." 2. "I have been taking good care of it." 3. "My friend is having a pool party and I am unsure how to deal with it."

1._____________related to altered body structure, as evidenced by the patient stating "I have a bag hanging off of me with stuff coming out. I hate it. I don't want anyone to ever see it." 2._____________ related to lack of motivation as evidenced by declining to do self-ostomy care. 3.___________ related to altered body structure. 4.______________related to lack of self-care.

1. Disturbed Body Image 2. Self-Care Deficit 3. Risk for Social Isolation 4. Risk for Impaired Skin Integrity

The client is to perform ostomy self-care. 1.___________ in self-care helps improve 2.__________. The nurse needs to help promote the client's 3.____________ as it enhances 4.____________.

1. Independence 2. Acceptance of the situation 3. Sense of control 4. Self-confidence

The nurse is collecting subjective and objective data from the client. What part of the nursing process is this?

Assessment

The nurse wants to have John view his stoma and participate in self-care. Which of the following solutions could assist John in meeting this outcome?

Bring in a mirror and encourage John to watch ostomy care

John continues to ask what foods he can eat with an ostomy? This cue would indicate a problem with which of the following?​

Deficient knowledge​

John's plan of care identified the following nursing diagnoses:​ -Risk for impaired skin integrity​ -Self-care deficit​ -Disturbed body image​ -Risk for social isolation​ The nurse selected Disturbed Body Image as the priority diagnosis. Which diagnosis should the nurse address next?

Self-care deficit