Bowel Elimination and Ostomy Care
a nurse is preparing to administer an oil retention enema to a client who has constipation, the nurse should instruct the client to retain solution for which duration? 1. duration of procedure 2. 10 to 15 minutes 3. until client feels urge to defecate 4. at least 30 minutes
1. (incorrect) enough time to lube rectum and distal portion of colon but not enough time for oil to penetrate feces and soften them to facilitate elimination 2. (incorrect) enough time to lube rectum and distal portion of colon but not enough time for oil to penetrate feces and soften them to facilitate elimination 3. (incorrect) too vague to ensure effectiveness, if they feel urge to defecate this might result in straining because oil has not had enough time to penetrate feces 4. (correct) this ensures effective softening of stool and lubrication of passageway
volume for large volume enema for toddler
250 to 350 mL
colostomy ascending colon
output is typically liquid to semi liquid and is very irritating to surrounding skin
foods that are difficult to digest and might cause blockage
stringy vegetables, coconut, coleslaw, mushrooms, popcorn, seeds, berries, celery, and fresh tomatoes
colostomy
-created from the end of the large intestine to divert waste from digestive system -end colostomy, loop colostomy, or double barrel colostomy
cut to fit barriers
-first 6 to 8 weeks following surgery when stroma changes in size and shape -use measuring guide and trace on to paper backing of skin barriers adhesive side -opening of skin barrier is cut to accommodate stroma size and shape but cut 1/8 inch wider to avoid tightness and allow for expansion
a nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy, which of the following information should the nurse include in teaching? 1. expect the effluent from the sigmoid colostomy to be loose and continuous 2. use irrigation to help establish a regular bowel pattern 3. change stroma appliance every other day 4. expect effluent from newly created stroma within 24 hours after surgery
1. (incorrect) for sigmoid colostomy effluent is solid and formed, a ileostomy is loose and continuous 2. (correct) can use irrigation to help control passage of stool, once they have established a regular bowel pattern, they can wear a stroma cap over the site but they do not need an external appliance 3. (incorrect) ostomy alliances can remain in place for up to 7 days 4. (incorrect) a newly created colostomy should expect effluent to begin draining within 2 to 5 days after surgery, clients with ileostomy can have drainage within 1 to 2 days
a nurse is replacing ostomy appliance for a client whose newly created colostomy is functioning, after removing pouch, which of the following actions should the nurse take first? 1. measure the stroma 2. cover stroma with gauze 3. remove the backing on skin barrier 4. cleanse the stroma and peristomal skin
1. (incorrect) not the first action but the nurse should measure stroma when changing appliance because the size changes as it heals 2. (incorrect) not the first action but the nurse should cover with cause when changing an appliance to absorb seepage during the process 3. (incorrect) the nurse should cover stroma with gauze when changing an appliance to absorb any seepage but not first action 4. (correct) removes any effluent adhering to stroma and skin to facilitate assessment of area
a nurse is teaching a client about extended wear skin barriers, which of the following strategies should the nurse instruct to client to use for maximal adherence? 1. use an oil based lotion on peristomal area 2. apply skin barrier while skin is slightly moist 3. leave residue from previous appliance on skin 4. press gently around barrier for 30 seconds to 1 minute
1. (incorrect) oil disrupts adhesion 2. (incorrect) if skin is moist, pouch will not adhere 3. (incorrect) remove residue because smooth surface improves adherence 4. (correct) pressure sensitive tackifiers and heat sensitive polymers of skin barrier require adequate pressure and warmth to ensure adherence
volume for large volume enema for a child
300 to 500 mL
Bedside Commode (BSC)
-a chair or wheelchair with an open seat, used at the bedside by the patient for the passage of urine and stool -if client is unable to get out of bed but cannot walk to bathroom
pre cut skin barriers
-after measuring stroma using guide, the appropriate size opening is selected -1/8 inch larger -after the stroma has a consistent size and shape
temporary colostomy
-allows bowel to rest or heal commonly after a tumor resection -common surgery would be leaving distal portion of colon in place which is overseen for closure to create a Hartmanns pouch -anastomosis of several portions of color may be delayed for several reasons including bowel inflammation or tumor location
Kock's continent ileostomy
-alternative to standard ileostomy -internal pouch created from distal segment of ileum that serves as stool resovoir -during surgery a one way nipple valve is constructed through stroll opening so client can insert catheter through stroma to drain fecal contents of internal pouch -used occasionally to treat ulcerative colitis and may be an option for client who doesn't want an external pouch -higher complication rate, client drains pouch several times a day, stroma is covered with protective dressing or cap
what stroma abnormalities should you report
-any stroma that has turned pale, dark red, purple, brown, or black as it can indicate compromised blood supply
replacing an ostomy pouching system
-ask if there are any questions and perform hand hygiene -replace when bowel is least active -raise bed to comfortable working height -disconnect from waist band if there -begin at one corner and push on underline skin as you remove -dispose of pouch -cleanse the stoma and peristomal skin with warm water and a washcloth -make sure surrounding is dry -clean hands and don clean gloves -inspect color and turgor of skin and note any skin problems or unusual -measure size and trace opening on paper back of the skin barriers adhesive side -cut opening about 1/8 inch larger to allow expansion -remove backing and place hole over stoma of skin barrier -apply pressure evenly and go around stoma to make sure it is sticking to the skin -connect pouch to skin barrier and snap in place -reconnect waist band if applicable -dispose of waste and perform hand hygeine -advise patient to stay in place for optimal adhesion -document all assessment information, time, date, and pouch system
one piece drainable pouch systems
-attached skin barrier -available in cut to fit or pre cut
fracture bedpan
-bed rest, immobilized and unable to use bathroom or commode -clients who are in body or leg casts, lower extremity factor, or are unable to raise hips -hard plastic with flat upper end that makes sliding bedpan under client easier
drainable pouches
-can be rinsed and reused -recommended for ascending or transverse colostomy, ileostomy, and urostomy -drainable urostomy pouches have tap instead of clip -choosing well fitting pouching systems is essential for preventing irritating stool, urine, or mucous from contacting skin surface -to help maintain best fit, determine size and shape of stroma using measuring guide
yeast infection of peristoma
-candidiasis -leakage, perspiration, antibiotic therapy, or broken skin -itchy, bumpy, reddened skin -apply topical anti fungal powder and keep skin clean and dry
general postoperative ostomy information
-clients should follow up regularly with surgeon and wound, ostomy, and continent nurse -most clients can resume usual activities with minimal restrictions after stroma has healed adequately -ostomy clients should be advised to remain vigilant of their hydration status during strenuous physical activity -clients should engage in a regular exercise routine that includes activities that promote cardiovascular and musculoskeletal fitness -encourage clients to share feelings of sensitivity and concern with partners if engaging in sex -irritation of stroma and peristomal skin due to friction should be avoided -clients may feel more secure engaging in sex if they empty pouch first, wear small pouch, cover pouch with special underwear lingerie or pouch covers
irritant dermatitis to peristoma
-contact with stool or urine usually fro leakage under pouching system or between skin barrier and stroma -reddened, moist, painful skin -clean and dry skin, use protective skin barrier powder or wipe skin before applying skin barrier -remeasure strome to ensure use of correct size pouch and or skin barrier
large volume cleansing enema
-container or bag for fluid with rectal tube attached, solution to be instilled, water soluble lubricant, and IV pole to hang container or bag -administered to expel intestinal gas -large volume in small increments (100 to 200mL at a time) -in rectum in sigmoid colon to stimulate peristalsis -after instilling, lower container to allow solution to flow back and forth into container -procedure helps increase peristalsis and relieve flatus
continent ileal bladder conduit (Kocks pouch)
-created same way as ileal conduit except the nipple valves formed by intussuspecting tissue backward into -pouch is connected to skin and ureters are connected to pouch -filling pressure closes valves preventing leakage and reflux -external drainage collection device not necessary because client self catheterizes every 4 hours -may be discharged with drains still intact in surgical opening -teach how to care for drains and insertion sites during time before removal -use precut 4 by 4 inch drain dressing to absorb leakage
draining an ostomy pouch
-drain when bowel is least active -raise bed to comfortable working height -place water proof barrier under pouch -tilt bottom of pouch upward and remove clamp -for easy cleaning of thick fecal matter, fold ends backwards to make cleaning easier -place granulated cylinder beneath opening under pouch -empty -clean opening of pouch before replacing clip -perform hand hygiene -bring bed back down for patient -document color consistency and amount of effluent -donn gloves and dispose of waste material in proper place
ileal conduit
-entire bladder is removed -loop of intestinal ileum is separated and used as conduit for urine -ureters are attached to ileal conduit and open end is brought out through abdominal wall to form a stroma -remaining ileum os reconnected to rest of digestive tract -most common
allergic contact dermatitis to peristoma
-exposure to materials and chemical compounds that irritate the skin on contact (tape, soap, skin barriers, adhesives, powders, pastes) -redness and irritation in area covered or treated with product -alter pouching system or skin care procedure to eliminate irritating product
regular bedpan
-hard plastic but curved smooth upper end and tapered lower end -clients who are able to lift hips and have no mobility restrictions of lower extremities
postoperative ileostomy
-higher risk of fluid and electrolyte balances due to shorter transit time through bowel, decreased absorption of fluid and nutrients, and higher volume of effluent -high volume ileostomy effluent can deplete sodium and potassium quickly -to prevent dehydration and blockage drink 80-96 ounces of water a day -over time the ileum adapts and takes over functions of large intestine including water and sodium absorption -gradually resume regular diet -chew food thoroughly -should avoid high fiber foods 6 to 8 weeks after surgery -take enteric coated pulls with caution and observe for undissolved medication in ileostomy pouch -drainage is usually dark green, loose, and odorles -empty pouch one third to one half full -use skin barrier and prompt attention to any indications of pouch leakage -effluent from ileostomy contains enzymes and bile salts that can irritate skin -report manifestations of food blockage -if stroma is swollen they may have to replace pouch with one that has a larger opening to avoid mechanical obstruction -know manifestations of dehydration or electrolyte imbalances
what is hydronephrosis and how does this occur after urostomy surgery
-hydronephrosis is the enlargement of kidney's as urine collects in renal pelvis and kidney tissue that can lead to renal damage -after surgery, tissue edema and bleeding can interfere with urinary output -after surgery maintain clients urine output 30mL per hour to prevent hydronephrosis -assess color and consistency of urine, some cloudiness indicates mucous but excessive cloudiness and foul odor are signs of infection
things to tell client to notify clinical of relating to stroma and peristroma
-increased pain in abdomen or incision -fever, redness, or drainage of incision -irritation, redness, or breakdown of peristomal skin -change in bowel habits (diarrhea or constipation) -skin irritation unrelieved by properly fitting pouching system -problems obtaining a good seal of wafer or skin barrier -hernia or bulge around stroma -narrowing of stroma lumen -separation of stroma from abdominal surgace -lacerations or cuts in stroma
stroma care
-inspect daily -clean routinely with warm water -usually pink to red -sweling decreases with time
Enema
-involves instilling a solution into rectum and sigmoid colon to stimulate peristalsis and promote defecation -relieves constipation, expel flatus, empty bowels before diagnostic procedures or surgery, or initiate bowel training program
normal saline for enema
-isotonic so it will not pull or shift electrolytes or fluid in or out of colon -reduces risk of electrolyte imbalance and fluid volume excess or deficit, -infants only receive normal saline
cleansing enema
-large or small volume -when solution is instilled, bowel is stretched stimulating peristalsis -solutions include tap water, normal saline, and soapsuds -amount of solution varies with age -takes 10 to 15 minutes
what position is best for clients when administering an enema?
-left side in sims or left lateral position with right knee flexed -this allows proper exposure of the anus and allows solution to flow downward by gravity along the curve of sigmoid colon and rectum to improve effectiveness
medicated enema
-local effect they exert on rectal mucosa like antibiotic or systemic effect like sodium polystyrene for hyperkalemia -administered by nurse
colostomy sigmoid colon
-location for permanent colostomy usually for cancer of rectum -stroma is located on lower left quadrant of abdomen -output is formed
colostomy transverse colon
-location used for temporary ostomy with the stroma constructed as a loop -output is pasty
loop colostomy
-loop of bowel is brought through abdomen to skin surface and is temporarily supported by plastic bridge or rod -transverse loop is typically an emergency procedure to relieve intestinal obstruction of perforation -communicating wall remains between proximal and distal bowel -two openings through one stroma -proximal end drains stool -distal end drains mucus -bridge canoe removed in 7 to 10 days -transverse loop colostomies are temporary
postoperative colostomy
-most patients can resume regular diet including fresh fruits and vegetables, protein, whole grain bread, and cereals -dietary adjustment might be necessary for clients who develop diarrhea or take antibiotics -initially avoid foods that might cause blockage -suggest aversions and consumptions of certain foods based on what symptoms patient is experiencing -patients must speak to surgeon or PCP before using laxatives and enemas for potential fluid and electrolyte imbalance -use caution when taking enteric coated and sustained release medications -clients who have temporary diverting colostomy might feel urge to defecate through rectum or have rectal drainage -clients who have double barrel or loop colostomy should be aware that distal bowel carries no fecal contents -client can choose between pouch systems
two piece drainable pouch systems
-needs frequent pouch changes -minimizes skin breakdown -pouch and skin barrier connected with a flange mechanism -pouch may be disposable or reusable and may have filter for gas release
postoperative urostomy
-no dietary restrictions -avoid foods that can cause odor if wanted -to avoid infection and maintain urinary function clients should consume palely of fluid each day unless otherwise indicated -ileal conduits can increase risk of electrolyte imbalance with potential of metabolic acidosis
Uterostomy
-one or both ureters are redirected from kidneys through abdominal wall to form a stroma -two collecting devices that connect the ureters internally and bring one out through abdominal wall is transureteroureterostomy
closed end pouches
-one time use -meet needs of a client who irrigates -filter designed to reduce odor and gas buildup -no drain or clip -recommended for sigmoid colostomies -when pouch is full it is removed from skin barrier and discarded
stroma
-opening in the skin of abdomen -communicating end of the bladder or bowel that is brought to surface of the abdomen -should be shiny, moist, and red in color like mucous membranes of mouth and can be round or oval, protruding, flush with skin, or retracted
how to position bedpan
-place upper end underneath buttocks and lower end under upper thighs semi fowlers or high fowlers -keep linens from becoming wet or soiled by placing waterproof pad under client before positioning bedpan
Administering Enemas
-preheat to lukewarm -lubricate tip of rectal tube before insertion -point tip of enema tube towards client umbilicus while inserting
skin barriers
-protects skin from stroma output and attaches pouch to body -make sure skin is dry to ensure pouching system stays in place -If skin is not intact use appropriate skin treatment or protection product before applying pouch -remove barrier beginning with one corner and slowly pull remaining adhesive -use an adhesive remover wipe if necessary but check for hypersensitivity by doing patch test first -have client report any burning or itching beneath or purulent drainage around stroma -notify provider if any skin irritation, breakdown, rash, or unusual appearance of stroma or peristomal area -emphasize to measure stroma weekly over first 8 weeks to verify opening of pouch is correct size -must fit so skin at base of stroma is covered but doesn't constrict or exert pressure -if stroma size changes report refitting with a wound, ostomy, or continence nurse
soapsuds for enema
-pure castile soap, any harsher soap will cause bowel inflammation -stimulate peristalsis through intestinal irritation -usually 5 mL soap in 1 liter of solution -use cautiously in pregnant or older adults because can lead to electrolyte imbalances and damages intestinal mucosa
colostomy irrigation
-raise head of bed to working height -place absorbant pad -carefully remove ostomy pouch -remove any fecal matter from opening -secure irrigation sleeve using flange mechanism -use cone to opening of stoma after lubricating -unclamp irrigation tubing and slowly fill water -if client reports cramping slow or stop flow -may take about 45 minutes -once irrigant is eliminated empty it and remove irrigation sleeve -clean peristomal area -clean and place new colostomy skin barrier and pouch
carminative enemas
-relieve flatus and abdominal distention -small amount of fluid instilled into rectum with magnesium and glycerin -distends rectum and colon and stimulates peristalsis
hypertonic solutions for enema
-sodium phosphate -pull fluid from interstitial spaces into colon -should be avoided in young infants and dehydrated patients -OTC product that does not need a prescription
continent urostomy care
-surgeon may insert catheter to provide continuous drainage in immediate postop period -regular irrigation of indwelling draining tube may be indicated to prevent blockage
ileostomy
-surgical opening created in ileum to bypass the entire large intestine -stroma usually located in lower right quadrant -restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) involves connecting ileum to new anal pouch and is made out of portion of ileum -procedure of choice in cases where rectume can be preserved allowing client to retain anal sphincter and control of bowel movements -client will have temporary loop ileostomy to diver stool while new anal pouch heals followed by closure of ostomy a few months later -because ileum contains digestive enzymes and acid that can cause skin irritation, they must be extra careful to keep waste materials from contacting abdominal surface -initial stool output may be as high as 2,000mL per day putting them at risk for dehydration
hypotonic solutions for enema
-tap water -exert osmotic pressure causing water to move from colon into interstitial space -should not be repeated for water toxicity and circulatory overload
urostomy management
-teach about odor management, skin care, adequate fluid intake, pouch application and leakage prevention, self catheterization, and signs of infection and obstruction -teach them to evaluate character and color of urine -report any skin alterations under skin barrier that may be sign of leakage or need of extended wear skin barrier
ileal conduit care
-temporary bilateral ureteral stent may be placed to prevent post surgical edema from obstructing urine output -stents left in place 10 to 21 days after surgery
end colostomy
-the damaged section of the bowel is removed and the working end is brought through the abdomen to the skin surface -usually permanent
double barrel colostomy
-two separate storms are created -both ends of bowel are brought through abdomen to skin surface as two separate sections -distal colon is usually not removed but bypassed -proximal functional stroma diverts feces to abdominal wall -distal stroma or mucous distal expels mucus from distal colon
urostomy
-urinary diversion that allows urine to exit the body after removal of diseased or damaged section of urinary tract -urine will flow as its produced
small volume cleansing enema
-usually prepackaged -plastic container prefilled with solution with attached rectal tip and water soluble lubricant -hypertonic solutions -administer room temperature -take effect within 5 to 10 minutes
oil retention enema
-usually prepackaged, with plastic container refilled with solution and attached rectal tip with water soluble lubricant -lubricates rectum and colon -room temperature -oil absorbed by feces making softer and easier to past -patient retains enema for minimum of 30 minutes
indications for ostomy surgery
-when a disorder or injury keeps urinary or gastrointestinal tract from functioning properly -congenital abnormalities -bladder, colon, and rectal cancer -inflammatory bowel diseases (crohns disease, ulcerative colitis) -inherited disorders -obstruction of the ureter -stab or gunshot wounds to abdomen
length of enema tube for an infant
1 to 1.5 inches
a nurse is teaching a client who has bladder cancer about urinary diversion options, the nurse should inform client that which following options will allow them to have some control over urinary elimination? 1. kock's pouch 2. ileal conduit 3. cutaneous ureterostomy 4. nephrostomy
1. (correct) is a continent ileal bladder conduit that does not require external drainage collections device because client self catheterizes every 2 to 4 hours to remove urine 2. (incorrect) this is a passageway that allows urine to flow from kidneys to outside of body and is uncontrollable 3. (incorrect) diversion that allows urine to from from ureteral opening to outside of body by flowing through stroma as it is produced and is uncontrollable 4. (incorrect) diversion that allows urine to flow from kidneys to outside of body through tubes placed in renal pelvis, urine flows as its produced and is uncontrollable
a nurse is preparing to administer a cleansing enema to a client who has poor sphincter control, which of the following actions should the nurse take? 1. place client in dorsal recumbent position on bedpan 2. administer enema while client sits on toilet 3. administer an antidiarrheal medication 3hr prior to enema 4. instill 200mL of fluid over an hour at 15 minute intervals
1. (correct) poor sphincter may not be able to retain enema solution at all, this position after instillation of rectal tube will help contain fluid that is likely to expel 2. (incorrect) angle of insertion tube could cause abrasion of rectal wall 3. (incorrect) will not correct poor sphincter control and be counterproductive to purpose of enema 4. (incorrect) unnecessarily prolong procedure and have little or no effect on sphincter control
a nurse is obtaining health history from a client who has a colostomy. the client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. client tells nurse they have avoided social activities due to fear of leakage. which of the following should the nurse recommend? 1. consume foods low in fiber content 2. take an ounce of mineral oil twice a day 3. add buttermilk and cranberry juice to diet 4. increase water intake 3 to 3.5 L per day
1. (correct) thicken the stool 2. (incorrect) produces laxative action by lubricating stool and reducing water absorption from stool 3. (incorrect) control stool order but does not relieve diarrhea 4. (incorrect) recommended fluid intake for ostomies are 2 to 3 L because they are at risk of dehydration but increasing fluid intake does not relieve diarrhea
a nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? 1. warm the enema solution prior to instillation 2. prepare 1,500mL of enema fluid 3. use tap water as the enema fluid 4. hang enema container 24 inches above the anus
1. (correct) warm enema solution prior to instillation because cold fluid can cause abdominal cramping, If it is too hot it can injure intestinal mucosa 2. (incorrect) for large volume cleaning enema the amount of fluid for adult client is between 750mL and 1,000mL 3. (incorrect) tap water is hypotonic solution that moves fluid from colon to interstitial spaces and can cause circulatory overload and electrolyte imbalance, this treatment cannot be given more than once and this patient is prescribed two 4. (incorrect) the height of fluid container affects speed, so the maximum recommended height is 18 inches, any higher can cause rapid instillation and painful distention of color
a client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. the nurse should expect the provider to prescribe which of the following types of enemas? 1. cleansing 2. return flow 3. medicated 4. oil retention
1. (incorrect) cleansing removes feces if client is constipated, has fecal impaction, or is undergoing preparation for surgery or diagnostic procedures, this does not meet immediate need 2. (correct) return flow or flush enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention 3. (incorrect) medicated reduces bacteria in color prior to surgery or exert systemic effect, this does not meed immediate need 4. (incorrect) oil retention lubricates rectum and colon making feces softer and easier to pass, this does not meet immediate need
while a nurse is administering a cleansing enema, the patient reports abdominal cramping. which of the following actions should the nurse take? 1. measure vital signs 2. notify PCP 3. lower enema fluid container 4. stop enema instillation
1. (incorrect) does not relieve discomfort 2. (incorrect) does not relieve discomfort 3. (correct) some cramping is to be expected, the nurse should slow the rate by reducing height of enema fluid container 4. (incorrect) stopping procedure only is indicated if abdomen becomes rigid and distended or if there is evidence of bleeding
a nurse is reinforcing teaching with a client about replacing an ostomy pouching system, the client reports they occasionally experience pain when removing skin barrier, which of the following techniques should the nurse suggest? 1. lift up on both sides of skin barrier simultaneously 2. release one corner of the barrier and pull it quickly over the stroma 3. push the skin away from barrier while removing it 4. gently roll the barrier end over end across stroma
1. (incorrect) pulls directly on dermis and can traumatize skin 2. (incorrect) can cause skin stripping 3. (correct) helps prevent skin stripping 4. (incorrect) pulls directly on dermis and can traumatize skin
a nurse is administering a return flow enema to a client. after instilling 100mL of enema fluid, which of the following actions should the nurse take? 1. instruct client to retain the fluid 2. lower the container to allow solution to flow back out 3. help client to toilet or bedside commode 4. wait 5 minutes and instill another 100mL of fluid
1. (incorrect) retain fluid is appropriate for retention enema, not return flow 2. (correct) return flow enemas involve moving 100 to 200 mL of fluid in and out of rectum. after instilling, the nurse lowers container to allow solution to flow back into container and then repeats process several times 3. (incorrect) appropriate for cleansing enema, not a return flow enema 4. (incorrect) inappropriate for return flow
a nurse is preparing an adult client for an enema, the nurse should assist the client into which position? 1. prone 2. dorsal recumbant 3. right lateral with both knees at chest 4. left lateral with right leg flexed
1. (incorrect) self explanatory 2. (incorrect) used for infants and small children but is not optimal for adults 3. (incorrect) difficult position to maintain and is an unnecessary extreme for enema 4. (correct) makes it easier for enema solution to flow by gravity into sigmoid and descending colon, the flexed leg promotes exposure of anus for insertion of rectal tube
a nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire intestine and rectum. the nurse should reinforce with the client that they are scheduled for which of the types of ostomy procedure? 1. cecostomy 2. loop colostomy 3. ileostomy 4. descending colostomy
1. (incorrect) surgical opening created in cecum with an opening to abdominal wall for diversion of feces, is not possible if entire intestine is removed 2. (incorrect) temporary storm created by pulling a loop of intestine onto abdominal wall creating two openings into loop, is not possible if entire intestine is removed 3. (correct) provider will create ileostomy to divert feces from small intestine to abdominal surface and into ostomy pouch 4. (incorrect) removes portion of descending colon and using remaining section to crease stroma to outer surface of abdomen, is not possible if entire intestine is removed
a nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of peristomal skin after they returned home. which of the following instructions should the nurse include? 1. apply hydrocortisone cream to skin when changing appliance 2. empty pouch when it is less than half full 3. wash the peristomal skin frequently with deodorizing soap and water 4. choose a time shortly after a meal for replacing pouch
1. (incorrect) use only stony care products like skin sealants and ostomy skin creams when changing appliance 2. (correct) empty pouch in-between 1/3 to 1/2 full to decrease risk of leakage of ileostomy effluent that can be irritating to peristomal skin 3. (incorrect) avoid soap because the residue can interfere with pouch adhesion increasing risk of leakage. client should cleanse skin with warm tap water only, if soap is essential use mild pH balanced soap 4. (incorrect) change before a meal when active bowel evacuation is less likely
volume for large volume enema for infants
150 to 250mL
length of enema tube for a child
2 to 3 inches
which of the following is the maximum amount of enemas instilled without further instructions from a surgeon? 1, 2 , or 3 enemas?
3 enemas are the maximum, otherwise the client is at risk for fluid imbalances, electrolyte balances, and exhaustion
length of enema tube for an adult/adolescent
3 to 4 inches
volume for large volume enema for adolescent
500 to 750 mL
volume for large volume enema for an adult
750 to 1000 mL
a nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. which lengths should the nurse insert rectal tube? A. 2.5 cm to 3.75 cm (1 to 1.5 inches) B. 5 cm to 7.5 cm (2 to 3 inches) C. 7.5 cm to 10 cm (3 to 4 inches) D. 10 cm to 12.5 cm (4 to 5 inches)
A. (incorrect) appropriate for infant B. (incorrect) appropriate for child C. (correct) appropriate for adult D. (incorrect) length puts client at risk for bowel perforation
foods that thicken the stool
applesauce, bananas, cheese, pasta, and rice
foods that cause malodorous flatus
asparagus, beans, cabbage, eggs, fish, garlic, onions, and some spices
beverages and foods that increase intestinal gas
beer, broccoli, Brussel sprouts, cabbage, carbonated drinks, cauliflower, corn, cucumbers, dairy products, dried beans, mushrooms, onions, peas, and radishes
foods that are more likely to cause flatus and loose stools
chocolate, dried beans, fried foods, highly spiced foods, and raw fruits and vegetables
Urostomy
creation of an opening in the urinary tract, normally to divert urine flow away from a diseased bladder
manifestations of dehydration or electrolyte imbalance
extreme thirst, dry skin and oral mucous membranes, decreased urine output, weakness, fatigue, headache, dizziness, muscle cramps, abdominal cramps, nausea, vomiting, shortness of breath, and orthostatic hypotension
foods to avoid initially following ileostomy
follow a low reside diet and avoid high fiber or difficult to digest foods like popcorn, nuts, corn, celery, fresh tomatoes, figs, strawberries, blackberries, and caraway seeds
indiana continent urinary reservoir
formed from cecum and portion of ileum, the created stroma is continent and flush with skin, client self catheterizes to empty resovoir
common peristomal complications
irritant dermatitis, allergic contact dermatitis, and yeast infection
food blockage ileostomy
manifestations include: abdominal cramping, nausea, vomiting, swelling of stroma, and no ileostomy output for at least 6 hours intervention: client should lie down knee to chest to relieve intrabdominal pressure and or massage abdomen to promote peristalsis and fecal elimination
colostomy descending colon
output is semi formed because more water is absorbed while fecal material is in ascending and transverse colon
what is the desired effect of enema till clear administration
patient defecates a large amount of slightly discolored solution with no fecal matter
moldable skin barriers
pliable stroma opening that can be molded to provide a snug fit around the stroma
what actions should you take if you feel resistance or if client reports pain upon insertion of enema tube?
stop and ask client to take a deep breath and instill a small amount of fluid to relax sphincter or soften stool enough for tube or tip to be administered
enema solutions
tap water (hypotonic), normal saline, soap suds, hypertonic solutions, carminative, medicated, or oil
