HPA Exam 3: Elimination

How as a nurse can you address disturbed body image regarding an ostomy?

1) Encourage the patient to verbalize feelings regarding the stoma 2) Suggest the spouse or significant other view the stoma 3) Offer counseling 4) Arrange for a support group

What are attributes are important regarding bladder elimination?

1) Presence of urine 2) Passage of urine 3) Color of urine 4) Frequency of urine passage 5) Retention of urine 6) Amount of urine

How as a nurse can you address anxiety related to the loss of bowl control with an ostomy?

1) Provide information about the expected bowel function (frequency and characteristics of stool associated with location of ostomy) 2) Explain how to prepare the appliance for an adequate fit (should hug the stoma and cover the peristomal skin) 3) Demonstrate how to change the appliance or empty the pouch before leakage occurs 4) Demonstrate how to irrigate the colostomy and recommend that irrigation be performed at a consistent time

How as a nurse can you address deficient fluid volume that may occur with an osotomy?

1) Record intake and outtakes and daily weights to provide an indication of fluid balance 2) Assess serum and urinary potassium and sodium levels 3) Observe and record skin turgor and the appearance of the tongue

What is an ostomy?

A surgically formed opening from the inside of an organ to the outside. The intestinal mucosa is brought out of the abdominal wall, and a stoma, the part of the ostomy that is attached to the skin, is formed by suturing the mucosa to the skin. This allows this part of the intestine to empty into a bag that is attached to the stoma (opening). It can be a temporary or permanent procedure.

What does a pale stoma indicate?

Anemia

A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what? A) 50 mL B) 30 mL C) 125 mL D) 100 mL

B)

A nurse is completing discharge teaching with a client who is 3 days postop following a transverse colostomy. Which of the following should the nurse include in the teaching? A) Mucus will be present in the stool for 5 to 7 days after surgery B) Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks C) Stoma should be moist and pink D) Change the ostomy bag when it is 3/4 full

C) Stoma should be moist and pink

How often should the stoma bag be emptied?

Every four to 6 hours or when 1/3 full

What are patients with an ileostomy or ascending colostomy more at risk for?

Stool is less formed. So skin excoriation around the stoma can typically occur if the appliance is not fit properly. There is also more of a risk of nutritional and hydration deficiencies as water reabsorption is severely limited in these patients.

What is a cuteanous uretosotomy?

Surgeon brings the detached ureter through the abdominal wall and attaches it to an opening in the skin

How as a nurse can you address deficient knowledge regarding an ostomy procedure and preoperative preparation?

1) Ask whether the patient has had previous surgical experience, assess anxieties and fears, and attitudes towards surgery so they can be addressed 2) Determine what information the surgeon gave the patient and clarify as necessary. Determine whether the stoma is permanent or temporary 3) Let the patient know where the stoma will be located 4) Explain that oral/parenteral antimicrobial agents will be given to cleanse the bowel prior to surgery 5) Assist the patient during NG intubation if indicated. Measure drainage from the tube (NG is used to drain GI contents before surgery)

How as a nurse can you address imbalanced nutrition that may occur as a result of an ostomy?

1) Conduct a complete nutritional assessment to identify foods that increase peristalsis and instruct patient to avoid foods that may irritate the bowel 2) Advise the patient to avoid foods with cellulose or hemicellulose base such as nuts and seeds which may induce elimination and hold water 3) Recommend moderation in intake of irritating foods such as bananas, prunes, and grapes

What are some reasons a cutaneous urinary diversion maybe indicated?

1) Due to bladder cancer or other pelvic malignancies 2) As a result of trauma 3) Strictures 4) Neurogenic bladder 5) Chronic infection or intractable cystitis 6) Used as a last resort for incontinence

What are some things you should include in patient and family education regarding ostomy care?

1) Explain the reason for the bowel diversion and rationale for the treatment 2) Demonstrate self-care behaviors that effectively manage the ostomy 3) Describe follow-up care and existing support resources 4) Report where supplies may be obtained in the community 5) Verbalize related fears and concerns

What foods would you recommend a patients with a newly placed ileostomy avoid? (Select all the apply) A) Apples B) Tap water C) Corn on the cob D) Beer E) Watermelon

A) Apples, C) Corn on the cob, D) Beer

A patient's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A) Arrange for the patient to be seen by a social worker or spiritual advisor. B) Ensure that the patient knows that he or she will be responsible for care after discharge. C) Acknowledge the patient's reluctance and initiate discussion of the factors underlying it. D) Reassure the patient that many people are fearful after the creation of an ostomy.

C)

The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective? A) "I will not need to worry about being incontinent of urine." B) "A catheter will drain urine directly from my kidney." C) "My urine will be eliminated through a stoma." D) "My urine will be eliminated with my feces."

C)

he nurse is caring for a 13-year-old client with ulcerative colitis who has a new temporary colostomy. Which nursing intervention is priority? A) Set up home health care for the client. B) Discuss the process for colostomy reversal with the client. C) Teach the client how to perform colostomy care. D) Encourage the parents to care for the child.

C)

A client who recently had a colostomy expresses concerns about the sexual relationship with the client's spouse. Which statement made by the nurse is appropriate? A) "Let me speak with your spouse. Your spouse might be okay with it." B) "We have a psychiatrist available for sexual dysfunction therapy." C) "Give your spouse time to get over it." D) "I can refer you to a support group so that you can speak with others with similar problems."

D)

What is a nephrostomy?

Surgeon inserts a catheter into the renal pelvis via an incision in the flank or by percutaneous catheter placement into the kidney

What is a vesicostomy?

Surgeon sutures the bladder to the abdominal wall and creates an opening through the abdominal and bladder walls

What is a conventional ileal conduit?

Surgeon transplants the ureters to an isolated section of the terminal ilium, bringing one end to the abdominal wall

How as a nurse can you address the risk for impaired skin integrity with an ostomy?

1) Educate the patient on how to notice signs and symptoms of irritated skin and what a healthy periostomal skin should look like (slightly pink without abrasions) 2) Instruct the patient how to cleanse the peristomal skin (mild friction with warm water and a gentle soap and patting the skin dry) 3) How to apply a skin barrier 4) How to remove the pouch (gently separating adhesive from skin to avoid irritation, never pull!)

When should an ostomy start draining fecal matter?

About 24 to 48 hours after surgery for an ileostomy, about 3 to 6 days after surgery for a colostomy

How as a nurse can you address sexual dysfunction related to altered body image that comes with an ostomy?

1) Encourage the patient to verbalize concerns and fears 2) Recommend alternative sexual positions that avoid patient embarrassment and avoids peristomal skin irritation 3) Seek assistance from a sexual therapist or wound ostomy continence nurse

What are some reasons a patient may get a ostomy?

1) Extensive colorectal cancer 2) Bowel obstruction 3) Crohn disease 4) Diverticular disease 5) Trauma 6) Congenital abnormalities 7) Ulcerative colitis 8) Total colectomy or hemicolectomy

What should be included in pre-op care for a patient who is undergoing bowel diversion surgery?

1) Fluid and electrolyte replacement 2) Nutritional support: patient may receive small low residue meals before surgery. Provide education on foods that should be eaten after surgery (avoid foods that may irritate the bowel, avoid foods with cellulose or hemicellulose base such as nuts and seeds) 3) Provide emotional support (address any concerns prior related to body image or any anxiety) 4) Patient teaching (should primarily be done by an WOC nurse and include information about the ostomy, nature of drainage, intro to use of common stoma appliance, need for NG intubation, parenteral fluids, and possibly perineal packing) 5) Patient should have a thorough understanding of the surgery to be performed and what to expect afterwards

What are some potential complications that can occur as a result of ostomies?

1) Fluid volume deficits (specific concern with ileostomies) 2) Periostomal skin irritation (peristomal area should be regularly assessed, kept dry, cleansed, and when changing wafer should be removed gently in order to prevent skin abrasions) 3) Diarrhea (can quickly lead to electrolyte loss and dehydration) 4) Intestinal obstruction (occurs more often with ileostomies due to smaller ostomy)

Describe how to put on an ostomy appliance

1) Gently pat the peristomal area to make sure the skin is dry and assess the stoma and condition of the surrounding skin 2) Apply skin protectant to a 2 in (5 cm) radius around the stoma 3) Lift the gauze square and measure the stoma to 1/8 larger than stoma size and cut appliance (should hug stoma) 4) Remove the paper backing from the faceplate and ease the appliance over the stoma and apply gentle, even pressure for approximately 30 seconds 5) Close the bottom by folding the end upward and using the clamp or clip that comes with the produce to secure the Velcro closure

What are some dietary considerations that should be taken after bowel diversion?

1) Should eat a well-balanced diet 2) Avoid foods that are difficult to digest for at least the first 6 weeks (low fiber, low residue diet) 3) Should eat small, frequent meals each day 4) Introduce new foods one at a time 5) Eat food slowly and chew well 6) Eat foods that are cooked well and tender 7) Avoid drinking through a straw or carbonated drinks as it can cause gas and bloating 8) Should avoid seeds, celery, or cellulose products that can create a blockage with ileostomies 9) Should maintain adequate hydration (increase fluid intake, especially with certain activities)

What should be included in post-op care for a patient who has undergone bowel diversion surgery?

1) Should encourage early ambulation 2) Administer pain medications as prescribed 3) Observe the stoma for size and color (should be pink to bright red and shiny) 4) Accurate record of I & Os 5) Providing stoma and skin care 6) Patient teaching on how to care for the stoma, emptying appliance, nutrition 7) Transitional care

Describe what you should be assessing with an ostomy

1) Stoma should be assessed. Stoma color should be beefy, red, and moist. It may be slightly edematous after surgery with a small amount of discharge and bleeding (is an abnormal sign if bright red or more than trace amounts). 2) The peristomal area should also be assessed. Should be kept clean and dry and should appear like no normal skin with no signs of lesions. 3) Once output of stool begins (with ileostomy occurs within 24-48 hours, with other ostomies it can be between 3-6 days) the character and output of the stool should be measured

What attributes are important regarding bowel elimination?

1) The presence of stool/feces 2) The passage of stool 3) The form of stool 4) The color of stool 5) Frequency of stool passage 6) Retention of stool 7) Scope of elimination: from ingestion of food, digestion, to stool formation and elimination

A nurse is caring for a client who had an ileal conduit 3 days earlier. Which assessment finding, if made by the nurse, would indicate a need for a further consultation with the enterostomal nurse? A) stoma site not sensitive to touch B) beefy red stoma site C) clear mucus mixed with yellow urine drained from the appliance bag D) red, sensitive skin around the stoma site

D)

What interventions and assessments should the nurse be doing postop following an ileal conduit?

Should be measuring urine volumes hourly. Urine output below 0.5/kg/hr or 30 mL/hr may indicate dehydration or obstruction. A catheter may be inserted to monitor for possible stasis or residual urine. Should also provide emotional support to patient. Assure them that hematuria is normal for the first 48 hours and that mucus production from the stoma is normal due to mucus membrane conduit (encourage increased fluid intake to help flush mucus). Should assess for any abnormal bleeding and perfusion through the stoma (look for pink, healthy stoma). Should be aware of moisture in bed linens or clothing as it could indicate leakage or potential infection. Severe alkaline encrustation can accumulate rapidly around the stoma, so the pH should be kept below 6.5 by administration of ascorbic acid by mouth and regular urine pH assessments.

A nurse refers a client with a new colostomy to a support group. This nurse is practicing which aim of nursing? A) Preventing illness B) Facilitating coping C) Promoting health D) Restoring health

B)

What is a hemicolectomy?

Partial removal of the large intestine

What are some potential complications with urinary diversion?

1) Fluid volume deficit 2) Peristomal skin irritation (urine tends to be acidic) 3) Infection/Peritonitis 4) Ureteral obstruction 5) Small bowel obstruction 6) Renal calculi

What are important considerations with an Indiana pouch?

Pouch must be drained at regular intervals in order to prevent absorption of metabolic wastes from the urine, UTI, or reflux of urine into the ureters.

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image? A) The client touches the altered body part. B) The client avoids talking about the recent surgery. C) The client closes his or her eyes when the abdomen is exposed. D) The client asks the spouse to leave the room.

A)

A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client's care to: A) help the client cope with the anxiety associated with changes in body image. B) evaluate the client's need for mental health intervention. C) assess whether the client is a good candidate for surgery. D) assess suicidal risk postoperatively.

A)

A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage? A) Urine drains from it continuously. B) Stool continuously oozes from it. C) Peristalsis is greatly decreased. D) Absorption of nutrients is diminished.

A)

A client with bladder cancer had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? A) The pouch faceplate doesn't fit the stoma. B) Stoma dilation wasn't performed. C) A skin barrier was applied properly. D) The skin wasn't lubricated before the pouch was applied.

A)

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? A) dark pink and moist B) red and dry C) off-white or pale pink. D) dark or purple-blue.

A)

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? A) brussels sprouts B) rice C) green peppers D) lettuce

A)

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? A) The stoma is prolapsed. B) The stoma is on the abdominal surface. C) The stoma has a small amount of bleeding. D) The stoma is pink.

A)

A nurse approaches a client with a recent colostomy for a routine assessment and finds the client tearful. The nurse's most appropriate response would be to: A) assess the colostomy and encourage the patient to participate in colostomy care. B) sit down and ask if the client would like to talk about any concerns. C) ask if the client is experiencing any pain or discomfort and needs any medication. D) state that the nurse will give the client some privacy and offer to call the client's family for support.

B)

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document? A) "Colostomy bag intact without feces." B) "Ileostomy bag half filled with liquid feces." C) "Ileostomy bag half filled with hard, formed feces." D) "Colostomy bag filled with flatus and feces."

B)

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag? A) Steamed rice B) Baked beans C) Cooked pasta D) Fresh lettuce

B)

A nurse is caring for a patient who has had a sigmoid colostomy for six months. What is the expected outcome from that ostomy? A) Liquid stool B) Semi-formed stool

B) Semi-formed stool

The nurse is caring for a client with a cystectomy and ileal conduit (urostomy) for prior bladder cancer. Which statements by the client would indicate that teaching has been effective? Select all that apply. A) "I should eat a diet high in protein and carbohydrates." B) "Redness around the stoma should be reported to my physician." C) "This ostomy pouch is temporary until my surgery can be reversed." D) "It is important to observe the color and odor of my urine." E)"I understand that I will need to consume adequate amounts of fluids each day."

B), D), E)

Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply. A) Urinary retention B) Deficient knowledge: management of urinary diversion C) Chronic pain D) Disturbed body image E) Risk for impaired skin integrity

B), D), E)

A client is having trouble adjusting to a colostomy surgically created 4 days ago. The nurse prioritizes which nursing diagnosis? A) increased discomfort B) low self-esteem C) altered body image D) anxiety

C)

A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? A) Instruct the client to avoid prune or apple juice B) Instruct the client to keep a record of food intake C) Suggest fluid intake of at least 2 L/day D) Assist the client regarding the correct diet or to minimize food intake

C)

A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma? A) "The stoma is too moist; we must try to prevent skin breakdown." B) "The stoma is irritated; change the appliance more frequently." C) "The stoma looks healthy; continue your present care." D) "The stoma looks infected; you need an antibiotic cream."

C)

A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response? A) Obtain a sterile urine sample and send it for culture. B) Obtain a urine sample and check it for pH. C) Reassure the patient that this is an expected phenomenon. D) Report this finding promptly to the primary care provider.

C)

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care? A) Intermittent catheterizations B) Exercises to promote sphincter control C) Application of an ostomy pouch D) Irrigating the urinary diversion

C)

What is a continent ileal urinary reservoir (indiana pouch)?

Created for a patient whose bladder is not longer functional and was removed. Creates a urine pouch out of bowel (cecum and ileum), which the ureters are tunneled through and anastomesed with. The reservoir is made continent by forming a stoma. Urine collects in the pouch until a catheter is inserted and the urine is drained.

A client has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the client's body image? A) Provide the client with detailed written materials about the diversion at the time of discharge. B) Emphasize that the diversion is an integral part of successful cancer treatment. C) Allow the client to initiate the process of providing care for the diversion. D) Encourage the client to speak openly and frankly about the diversion.

D)

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? A) Urination can be voluntarily controlled after the stoma heals from the initial surgery. B) The client will need to change the urinary pouch every 4 hours. C) This urinary diversion is only temporary. D) The client will have to wear an external appliance to collect urine.

D)

The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention? A) Secure or patch it with tape. B) Empty the pouch. C) Secure or patch it with barrier paste. D) Change the wafer and pouch.

D)

What does a purple or darkened stoma indicate?

Ischemia or compromised stoma. Surgeon should be called immediatley

What is a total colectomy?

Removal of the entire colon including the rectum