Ostomy Care

Here's your challenge. You are working on a medical-surgical unit. One of your patients is a 30-year-old woman transferred from the post anesthesia care unit after ileostomy surgery for Crohn's disease. You perform a postoperative assessment and find the client alert, oriented, and responding appropriately. However, when you pull down the sheet to observe her abdomen, you observe a serious clinical manifestation. Her ileostomy pouch contains a significant amount of bright, red blood. What type of output is first expected from an ileostomy postoperatively? Please select from the options below. A.Loose, dark green liquid that may contain blood B.Serous discharge C.Formed to semi-formed stool D.Pasty yellow-brown stool

A.Loose, dark green liquid that may contain blood A - CORRECTYes. You have selected the correct response. This is the initial output seen from an ileostomy. Over time, the output will become more pasty and yellow-green or yellow-brown.

You note that the separation is approximately 3 mm deep.\ What is the best way to treat the separated area? Please select from the options below. A.Protect the area using powder and paste. B.Notify the provider since surgical correction is required. C.Fill in the "dead space" with an antifungal powder, such as miconazole. D.Use a convex appliance and stoma belt to prevent leakage of effluent.

A.Protect the area using powder and paste. A - CORRECTYes. You have selected the correct response. Protecting the area will promote healing. Follow this with the application of a properly fitting skin barrier and pouch.

After talking with your patient about her reaction to this body image change, she thanks you for taking the time to listen to and encourage her. While she feels better about what life might be like with her new colostomy, she tells you she is still confused about all the different pouch options available. She asks if you could explain the difference between a one-piece and two-piece pouching system. What should you tell her? Please select from the options below. A.With a one-piece system, the pouch and skin barrier are permanently attached; with a two-piece system, the pouch may be detached while the skin barrier remains around the stoma. B.A one-piece system does not include a skin barrier; a two-piece system does include a skin barrier with the pouch. C.A one-piece system allows the skin barrier to remain in place around the stoma for several days; a two-piece system does not allow this. D.With a one-piece system, the pouch must always be used with the manufacturer's skin barrier; with a two-piece system, she can use any skin barrier with any pouch.

A.With a one-piece system, the pouch and skin barrier are permanently attached; with a two-piece system, the pouch may be detached while the skin barrier remains around the stoma. A - CORRECTYes. You have selected the correct response. This is an accurate description of the difference between one-piece and two-piece pouching systems.

You have determined that you must assess the patient's abdomen first. You observe, auscultate, and palpate it. You find the abdomen is slightly firm, but not distended. The abdominal incision, closed with staples, is clean, dry, and intact. Bowel sounds are hypoactive in all four quadrants. Which of the following should you assess next? please select from the options below. A.Her urine output B.The suture line C.The stoma

B The suture line B - CORRECTYes. You have selected the correct response. After checking for signs of abdominal bleeding, assess the suture line, also called the mucocutaneous junction, for signs of frank bleeding due to injury of the mesenteric artery. The presence of frank bleeding is a medical emergency requiring the surgeon's immediate intervention.

On postoperative day 4, the patient reports a loss of appetite, drowsiness, and leg cramps. The output from the ostomy is 1,200 mL in the past 24 hours. You review the patient's most recent laboratory values: Which of the following is a likely cause of this electrolyte abnormality? Please select from the options below. A.Bleeding B.High-volume effluent C.Dehydration D.Renal failure

B.High-volume effluent B - CORRECTYes. You have selected the correct response. Ileostomy effluent contains many enzymes and bile salts. Hyponatremia can develop when the volume of effluent is high and fluids and electrolytes are not replaced adequately.

Hoping to discharge home as soon as possible, your patient reluctantly asks you to teach her about how to take care of her new colostomy. What is the best way to help your patient regain a sense of control and improve her self-esteem? Please select from the options below. A.Distract the patient with a book or movie while you provide her ostomy care during her hospital stay. B.Request her participation in her ostomy care as she is physically able. C.Encourage your patient to deny her fears, leaving them behind as she moves forward with her new life. D.Reassure her that she does not need to touch the stoma but encourage her to look at it.

B.Request her participation in her ostomy care as she is physically able. B - CORRECTYes. You have selected the correct response. Encouraging active participation in her own ostomy care will help your patient restore control over her lifestyle, thus increasing her self-esteem.

After explaining the risk factors, you give the patient information about caring for the area of separation, along with a follow-up appointment with the wound ostomy continence nurse. When the patient asks you about any other complications that could result from the separation, which of the following should you explain? Please select from the options below. A.Folliculitis B.Stagnated healing C.Prolapse D.Peristomal hernia

B.Stagnated healing B - CORRECTYes. You have selected the correct response. The separated area must be adequately protected from stoma effluent to promote healing. Failure to do so can result in delays in the healing process.

You assess the suture line carefully, but you do not see any bleeding, and it is intact and dry all around the edges. Which assessment should be your next step? Please select from the options below. A.Her urine output B.The stoma

B.The stoma B - CORRECTYes. You have selected the correct response. Assess the stoma for bleeding. Trauma to the stoma mucosa can also cause bleeding.

HISTORY On postoperative day 2, the patient's abdomen is soft with no signs of distention. You auscultate bowel tones in all four quadrants, and you note an increased amount of watery green effluent with gas in the ostomy pouch. The surgeon writes an order to start the patient on a liquid diet for 24 hours and advance it as tolerated. Preparing the patient to resume eating, you review the dietary recommendations with her. Which foods should your patient avoid to prevent blockage? Please select from the options below. A.Noodles and white bread B.Cream cheese and bananas C.Fresh tomatoes and celery D.Lean meats and poultry

C.Fresh tomatoes and celery C - CORRECTYes. You have selected the correct response. High-fiber foods, such as fresh tomatoes and celery, may cause food blockage. Other high-fiber foods to avoid are mushrooms, coconut, popcorn, and some shellfish, such as shrimp and lobster.

You determine that that this is a 5-mm partial separation at the inferior portion of the stoma. Which of the following should you do next? Please select from the options below. A.Allow the separation to remain open to air for several minutes with the pouch off. B.Fill in the "dead space" with skin barrier paste. C.Probe the area to determine the depth of the separation.

C.Probe the area to determine the depth of the separation. C - CORRECTYes. You have selected the correct response. Continuing the assessment process, you should use a sterile cotton tip applicator to probe the area gently to determine the depth of the separation.

You find the stoma to be pink, moist, and edematous with no signs of bleeding or trauma. You observe only watery greenish effluent coming from the stoma and no additional blood. After looking for the source of bleeding, you reassess the patient's status, including vital signs and urine output, for signs of hemorrhage. Decreased urine output could be related to hemorrhagic shock. Bloody urine may indicate damage to the kidneys or the urinary system during surgery or may be due to systemic causes including underlying disease or pharmacological therapy. The patient's urine output exceeds 30 mL per hour and is clear yellow in color. You review her medications, looking for any recent use of anti-inflammatory or antiplatelet medications, which could increase the likelihood of bleeding. After ensuring that she is not taking any of these medications, you conclude that the blood passed through the gastrointestinal tract from the internal mucosa. You point it out to the surgeon as she comes to the unit to assess the patient. You continue frequent checks of the patient's vital signs, abdomen, stoma, and effluent to make sure that the bleeding has ceased. ASSESSMENT Your patient's ostomy pouch is now one third full with watery green effluent. You decide to talk with the patient about selecting a pouching system. Which type of ostomy pouching system is appropriate for this patient at this time? Please select from the options below. A.A pouching system without a skin barrier B.A one-piece, closed-end pouching system C.A two-piece pouching system with a pre-cut skin barrier D.A one- or two-piece pouching system with a cut-to-fit skin barrier

D.A one- or two-piece pouching system with a cut-to-fit skin barrier D - CORRECTYes. You have selected the correct response. A cut-to-fit skin barrier will allow for custom sizing of the barrier to the stoma as it shrinks within 6 to 8 weeks after surgery.

After applying powder and paste, you apply a flat ostomy appliance that covers the separation, only exposing the stoma, to promote healing. You notify the surgeon and the wound ostomy continence nurse about the separation, and they arrive to evaluate the stoma. They agree with the current management plan. After the surgeon and the enterostomal therapist leave the room, the patient asks, "Why did the doctor say that I am at risk for this complication?" You explain that the risk of suture-line separation increases with which of the following factors? Please select from the options below. A.Lower abdominal location B.Antiplatelet medication. C.Cardiovascular disease D.Diabetes mellitus

D.Diabetes mellitus D - CORRECTYes. You have selected the correct response. Diabetes mellitus can increase the risk of mucocutaneous separation due to the microvascular changes that cause delayed or poor wound healing.

After 7 days in the hospital, your patient has made excellent progress toward independence with her ostomy care, and the surgeon has removed the supporting device from her loop colostomy. You have already educated her in several areas of ostomy care, but there are a few other items to discuss before she is discharged. Which of the following should also be included in your patient education? Please select from the options below. A.Colostomy irrigation B.An intermittent catheterization schedule C.Resumption of normal activities, including travel and sex

C.Resumption of normal activities, including travel and sex C - CORRECTYes. You have selected the correct response. Resumption of normal activities should be discussed with your patient. This includes work, travel, sexual activities, and lifting heavy objects.

What strategies should I use to prevent complications after stoma retraction?

A retracted stoma has pulled back below the level of the skin and appears as a concave defect on the abdomen. For a stoma that is flush or retracted, convexity may improve wafer adherence. A convex wafer presses into the tissue around the stoma, increasing the degree of stomal protrusion and reducing the risk of undermining of stomal output beneath the pouching system. In addition, it provides contouring to fill uneven areas of the skin around the stoma and support the peristomal field.

After the electrolyte imbalance is corrected and the patient is consistently stable, the surgeon writes discharge orders. The patient has demonstrated ileostomy self-care; however, she tells you that she is concerned about being with other people because of the odor. You ask her to recall the information you reviewed with her earlier about odor management. Which statement indicates that the patient understands the strategies she can use to avoid odorous gas? Please select from the options below. A."A well-fitted pouching system with a filter helps prevent odor." B."My friend suggested placing an aspirin tablet inside the ostomy pouch." C."I'll eat lots of cheese and eggs to minimize the odor." D."I'll just avoid social situations for an hour or so after I eat gassy foods."

A."A well-fitted pouching system with a filter helps prevent odor." A - CORRECTYes. You have selected the correct response. A well-fitted pouch will keep odorous gas from leaking. A pouch with a filter removes odors as gas passes through the charcoal layer.

The patient has now successfully changed her pouch with your help and that of her husband's, taking care not to dislodge the external rod used to support her loop colostomy. However, she would like to be able to do it on her own since after discharge, her husband will be at work during the day. She asks to further review some pouch change information with you. Which statement would indicate that your patient has a good understanding of how to place a new appliance? Please select from the options below. A."I should measure the stoma, then cut the appropriate size before removing the adhesive backing. My stoma will shrink over the next several weeks, so I'll need to measure it regularly." B."I should scrub my skin with warm water and dry it completely before applying the new pouching system. It's important for the skin to be dry before application." C."After applying the skin barrier, I should use some adhesive remover to be sure any residue is completely gone so that the pouch will adhere properly to the skin barrier. Adherence is important to prevent leakage." D."After I place the skin barrier, I should maintain gentle finger pressure around it for a few seconds. Then I can make a pinhole the pouch to prevent gas accumulation before snapping it onto the barrier."

A."I should measure the stoma, then cut the appropriate size before removing the adhesive backing. My stoma will shrink over the next several weeks, so I'll need to measure it regularly." A - CORRECTYes. You have selected the correct response. The statement is accurate and indicates correct understanding of this information.

You follow your discussion of pouching systems with a short explanation of the difference between pre-cut and custom cut skin barriers, as well as disposable and reusable pouches. After you answer your patient's questions regarding ostomy appliances, you proceed to talk with her about taking care of the skin around her stoma. Which information about peristomal skin care would be correct to tell your patient? Please select from the options below. A.Colostomy patients have a higher incidence of skin problems than ileostomy patients. B.The peristomal skin may be slightly red and excoriated. C.The pouch should be frequently checked for signs of leakage. D.The most common cause of peristomal skin disorders is chronic illness.

C.The pouch should be frequently checked for signs of leakage. C - CORRECTYes. You have selected the correct response. Effluent on the skin causes irritation and even erosion of the peristomal area. If necessary, a different product or care strategy may need to be implemented to protect the peristomal skin.

When should I consider colostomy irrigation?

Colostomy irrigation helps some patients avoid fecal discharge for about 24 hours. Although not required to maintain bowel function, it can be used to improve the regularity of bowel movements and thereby improve quality of life. Candidates for colostomy irrigation include those who have:a descending or sigmoid colostomya history of regular bowel habits prior to surgerythe desire to learn and perform the proceduremanual dexterity and visual acuityaccess to running water and bathroom facilitiesthe ability to perform the procedure on a regular scheduleno signs of stomal prolapse or peristomal hernia

Here is your challenge. You are working on a medical-surgical unit. You are assigned to care for a 62-year-old man admitted to your unit 5 days ago after the creation of a sigmoid colostomy due to rectal cancer. He has type 1 diabetes mellitus, osteoarthritis, and cardiovascular disease. He is now beginning to manage his ostomy pouch changes. As you enter his room for a routine assessment, he tells you he has developed some pain and burning at the stoma site. You note that the skin around the stoma appears erythematous but he denies any contact of the skin with fecal matter or mucus. You decide to remove the pouch to assess the stoma more closely only to find a 5 mm mucocutaneous separation. Which of the following should you do first? Please select from the options below. A.Flush the area with normal saline solution. B.Fill in the "dead space" with skin barrier paste. C.Probe the area to determine the depth of the separation. D.Inspect the circumference of the stoma. D.Inspect the circumference of the stoma.

D - CORRECTYes. You have selected the correct response. Separation at the suture line is a complication that can develop in the immediate postoperative period. According to the nursing process, assessment (beginning with inspection) precedes intervention. So, examine the stoma closely to determine the parameters of the separation.

Here is your challenge. You are working on a medical-surgical unit. You are assigned to care for a 56-year-old woman who is 3 days postoperative following the emergent creation of a temporary transverse loop colostomy. She has made satisfactory progress in pain control and diet advancement. Even though her ostomy is intended to be temporary, the patient has expressed that she feels both grieved and angry whenever she thinks of what life will be like with an ostomy. The patient's husband is at the bedside and plans to help her at home after discharge. Your patient's stoma is red and moist, and the pouch contains a small amount of liquid stool. What psychosocial assessment indicates a normal response to the alteration in body function your patient has just undergone? Please select from the options below. A.Anxiety and refusal to eat B.Severe depression, sometimes with suicidal ideation C.Confidence that life will be back to "normal" upon discharge home D.Anger and feelings of loss

D.Anger and feelings of loss D - CORRECTYes. You have selected the correct response. Normal responses to an alteration in body function include anger, feelings of loss, depression, and sadness.

How should I manage an ostomy with high-volume effluent?

Particularly with an ileostomy, watery to pasty stool may initially exceed 1,400 mL per day. To prevent dehydration, recommend copious amounts of water and sport drinks containing electrolytes, especially during exercise and in hot weather. Various high-output pouching systems hold a greater volume of effluent, but these are heavy when full. The high volume of enzymes in ileostomy effluent can corrode the skin, making peristomal skin protection a high priority. Extended-wear skin barriers with skin barrier paste help prevent leakage and maceration of the peristomal area. Attaching an ostomy appliance belt to the pouching system may help support the pouch's weight and maintain the skin barrier's seal.

What factors should I consider when selecting an appropriate solid skin barrier for a patient with an ostomy?

Solid skin barriers contain several ingredients that help them adhere to the skin's surface:polymers, heat-sensitive ingredients that fill in the creases and crevices of the skin's surface to promote adhesionhydrocolloids (carboxymethylcellulose, pectin, gelatin), which absorb perspiration and other metabolic secretions while preventing fungal and bacterial invasionThe cohesion, or ability of the skin barrier to maintain its integrity when exposed to moisture, varies with each product. Extended-wear skin barriers, for example, are more cohesive than standard wear adhesives and are designed for ostomies with watery or high-volume effluent. The product's cohesion is a factor in how well it protects the skin, maintains a seal around the stoma, and withstands moisture. However, it also determines how much residue remains on the skin after its removal. A skin barrier with high cohesion may leave residue that requires solvents to remove it. Your assessment of the individual's skin surface and integrity, amount of perspiration, characteristics of the effluent, and the personal preferences can help you find the appropriate barrier.