CH. 48 Caring for Clients With Ostomies

A client scheduled for an ileostomy asks what type of device will need to be worn over the stoma. Which response should the nurse make to address this client's question?

- "I can have the ostomy nurse discuss the different appliances with you." Explanation: For the client having surgery to create an ostomy, if the client expresses a readiness to learn or asks questions about ostomy care, the nurse should provide information about ostomy equipment and general principles of ostomy management. And, if the client so desires, the nurse should arrange a preoperative visit with the Wound and Ostomy Care (WOC) nurse. Teaching about the appliances can either help with acceptance of the device or cause undo stress. The client asking questions about the device indicates an interest that should be supported with more information. The client is not worrying about the device but rather is curious and is asking questions that should be supported with teaching. Teaching about the ostomy appliance should occur before the day of discharge.

- The nurse is caring for a client who had a Loop Transverse colostomy performed because of a rupture of the colon from a diverticulitis abscess. The client asks the nurse when all of this will be over and life will return to normal. What is the nurse's best response to this client?

- "I think you may mean when the colostomy will be reversed. It all depends on how soon your colon heals but it's usually about two to three months." Explanation: Transverse colostomies are usually temporary and are reversed after healing of the colon is completed. In most cases this is after about 2-3 months.

The nurse instructs a client scheduled for a double-barrel transverse colostomy about the procedure. Which statement indicates to the nurse that the teaching provided to the client was effective?

- "I will always have two openings on my abdomen." Explanation: In a double-barrel transverse colostomy, two stomas are created that totally separate the colon into a proximal and distal colon. = The proximal colon excretes liquid to semi-formed feces and the distal colon excretes mucus. - A pouch needs to be worn at all times over the proximal end and a gauze dressing needs to be applied over the distal end. The stool is not formed from a transverse colostomy. A double-barrel transverse colostomy is not going to be reversed. The mucus or distal end of a double-barrel transverse colostomy does not need to be irrigated because this end secretes mucus.

A nurse is documenting the appearance of feces from a patient with a permanent ileostomy. Which of the following would she document?

- "Ileostomy bag half filled with liquid feces." Explanation: The patient with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.

A client with an ileostomy who has been discharged from the hospital calls the clinic and asks the nurse if he should take another one of his "potassium pills" because there is a waxy coating on the ileostomy from the pill. What is the best response by the nurse?

- "Some medications like this leave a "ghost" of the wax matrix coating, but it doesn't mean the drug wasn't absorbed." Explanation: Some preparations such as potassium chloride (Slow-K) leave a "ghost" of the wax matrix coating, but that does not indicate the drug has been unabsorbed. The client should not take another potassium supplement that could increase the risk of elevated potassium levels. The dose was not omitted, and there is not a defect in the medication; it is an expected effect.

The nurse is teaching a client with an ileoanal reservoir how to perform perineal exercises. After tightening the anus, for how many seconds should the client hold the contraction before relaxing?

- 10 Explanation: In a client with an ileoanal reservoir, perineal exercises involve tightening the anus as if trying to prevent a bowel movement and holding the contraction for a count of 10 seconds before relaxing. This reduces the risk for bowel incontinence by reestablishing anal sphincter control and enlarging the ileoanal reservoir.

The client expresses fears about looking at the stoma for the first time. What can the nurse inform the client will occur when he first views and touches the stoma?

- An assigned staff nurse will be there when the stoma is exposed for view. Explanation: Inform the client that an assigned staff nurse will be there when the client first views and touches the stoma. Such information gives reassurance that a familiar nurse will be available to answer questions and give support. The client will not be expected to perform stoma care directly after the surgical procedure because he will require medication for pain and discomfort. An expected outcome is that the client will be able to perform self-care of the stoma. The stoma will not be covered; it will have an appliance that is clear.

The nurse applies the ostomy appliance to a client who is recovering from ileostomy surgery. Which intervention should the nurse keep in mind to avoid any leakages from the appliance?

- Ask the client to remain inactive for 5 minutes. Explanation: When the nurse applies the ostomy appliance, the nurse should ask the client to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. Allow a small amount of air to be trapped in the pouch so that liquid feces will then drain to the bottom of the pouch. Make several pinhole-sized punctures at the upper edge of the pouch to allow excess gas to escape and decrease the tension on the pouch. The adhesive tape should be pressed from the stomal edge outward to prevent formation of wrinkles.

The nurse is changing the ostomy appliance of a client with a transverse colostomy. Which action should the nurse take when yeast is noted under the faceplate?

- Ask the health care provider to order nystatin powder. Explanation: When changing the ostomy appliance, the skin and stoma should be inspected carefully. If there is yeast growth present, the health care provider should be asked to prescribe nystatin powder. A hydrocolloidal dressing is used if the skin is excoriated and not for a yeast infection. A solvent is not used on the skin with evidence of yeast growth. The skin should have been cleansed with soap and water after the appliance is removed and before inspecting the stoma and the skin.

The nurse is caring for a client who received a Brooke ileostomy five days ago. The nurse, when assessing the ileostomy site, notes that the stoma appears to be extending out from the client's skin by approximately 1 inch. What is the nurse's best action at this time?

- Contact the health care practitioner immediately and report the finding. Explanation: While a moderate (1-2 inches) prolapse of the stoma usually doesn't require treatment, the health care practitioner must be notified immediately and will make the decision if this new occurrence requires some type of treatment. The nurse will never attempt to push the stoma back against the skin. Surgery will not be necessary if the prolapse is moderate so the nurse can wait until the health care practitioner has seen the client and made a decision about treatment if any.

The nurse is caring for a client with severe ulcerative colitis who will be having the diseased portion of the colon removed and an ileostomy placed. The nurse knows that the client will be seen by the surgeon and which professional prior to surgery to decide the best position for the stoma?

- Enterostomal therapy nurse Explanation: The client will be seen by an enterostomal therapy nurse, enterostomal therapist or a wound, ostomy, and continence nurse (WOCN) who assists the surgeon in selecting the site for the stoma and also helps with the client's educational needs. The client will work with a nutritionist to plan meals that work well with the ileostomy and will see the circulating nurse at the time of surgery and it is possible the client will be seen by a home care nurse but it is only the enterostomal therapy nurse will assist in selecting the site for the stoma.

Which of the following measures would the nurse recommend to an ostomate to help facilitate a regular bowel pattern without relying on irrigation? Select all that apply.

- Explanation: Methods to stimulate bowel elimination and a regular schedule include : - drinking prune or fruit juice - eating fiber-rich foods and dried fruits - performing mild exercise - using a stool softener, mineral oil, or milk of magnesia if recommended by the physician. The other measures should be avoided by ostomates.

The nurse is caring for a client recovering from surgery to create a stoma for an ascending colostomy. For which reason should the nurse change the ostomy appliance?

- Fecal material is present around the faceplate. Explanation: An ostomy pouch should be changed when it is loose or leaking. Changing the appliance minimizes the risk of fecal drainage entering the incision. The pouch that is 1/4 full does not yet need to be emptied; however, once it gets fuller, it should be emptied so that the weight of the pouch does not pull on the faceplate and the skin. A healthy stoma appears moist and shiny. A pain rating of 6 on a scale from 0 to 10 is not a reason to change the appliance; the client needs analgesic medication.

Which of the following statements about ostomy irrigation is true?

- For some patients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Explanation: This approach allows for the use of a small covering over the colostomy between irrigations instead of a regular appliance.

A male client has struggled for many years with Crohn's disease and has finally decided to have an ileostomy with hopes that this will improve the quality of his life. The nurse knows that which procedure will give the client the greatest chance of maintaining normal sexual function?

- Ileoanal anastomosis Explanation: An ileoanal anastomosis joins a section of ileum to create an ileal reservoir. This surgery as opposed to the total colectomy which is performed in the standard and continent ileostomies, preserves innervation to the male genitalia. The male client will not experience bladder dysfunction, erectile dysfunction or infertility.

A common nursing diagnosis for a patient who had a colostomy surgically created 6 months ago would be:

- Ineffective Coping impaired due to colostomy Explanation: A patient with a well-established colostomy would experience ineffective coping related to body image and the impact on friends and social interactions. Pain, fear due to loss of control, and dehydration would all be secondary concerns compared to the impact on their social situation.

The type of stool that will be expelled into the ostomy bag by a client who has undergone an surgery for an ileostomy will be:

- Liquid Explanation: Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.

The nurse documents the following finding for a client with a new ileostomy. Which action should the nurse take at this time? Client recovering from general surgery to create an ileostomy located on the right side of the abdomen. Drainage in collection bag watery, brown-green in color; stoma protruding approximately 3 cm from the surface of the abdomen.

- Monitor the stoma for changes. Explanation: Prolapse or protrusion of the ileostomy is fairly common. If it is moderate (1 or 2 inches or 2.54 cm to 5.08 cm), no treatment is required. The stoma should be monitored for changes. An ileostomy does not need to be irrigated unless it is blocked. Pressure should not be applied to the stoma because this could compromise blood supply. Changing the collection bag is not going to cause the stoma to retract.

A client recovering from surgery to create a stoma for an ascending colostomy develops abdominal distention and tenderness. Which action should the nurse take?

- Notify the health care provider. Explanation: After the client returns from surgery, assessments include: - taking vital signs - checking dressings - monitoring nasogastric tubes and IV infusions A sudden increase in pain and abdominal tenderness or distention is to be reported the health care provider immediately. The lower abdomen does not need to be palpated. A rectal tube may or may not be needed. The health care provider determines the amount of suction to be applied to the nasogastric tube.

Define Ostomy

- Opening between internal body structure and skin

A client scheduled for a sigmoid colostomy reports feeling anxious about the procedure. Which action should the nurse take to reduce the client's fears? Select all that apply. - Permit the client to express fears. - Explain preoperative procedures. - Assess previously used coping skills. - Allow time for the client to ask questions. - Ask what the client has been told about the surgery

- Permit the client to express fears - Explain preoperative procedures - Assess previously used coping skills - Allow time for the client to ask questions Explanation: A client having surgery to create an ostomy can cause anxiety related to a change in their health status and fear of the unknown. Actions to assist the client include: - permitting the client to express fears because this promotes communication with the client - PREOperative procedures should be explained to the client because this helps the client know what to expect - Previously used coping skills should be assessed because these methods are likely to be effective with the current situation. - Allowing the client time to ask questions also supports communication and helps reduce the client's anxiety. Asking what the client has been told about the surgery addresses knowledge deficiency and does not necessarily help reduce anxiety.

The nurse is caring for a client with a Brooke ileostomy and should know that what laboratory tests will be ordered on a regular basis for this client?

- Potassium and sodium levels Explanation: The client may lose more potassium and sodium because of the liquid nature of the feces that are expelled through the ileostomy. Kidney function doesn't need to be monitored because of the ileostomy nor does the type of white cells being produced. Ketosis would not occur as a result of the ileostomy.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?

- Sigmoid colostomy Explanation: Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as: - the site of the colostomy in the colon (sigmoid colostomy) - patient's and physician's preferences determine whether a colostomy is to be irrigated. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled.

The nurse is caring for a client who recently had a Brooke ileostomy and will place priority on what aspect of physical assessment?

- Skin integrity Explanation: Clients who have had a Brooke ileostomy have a stoma that drains into a pouch. The fecal matter contains digestive enzymes and acids which can quickly cause skin breakdown if the fecal material comes in contact with the skin. The other assessments would have higher priority immediately after the surgery.

A nurse is performing an assessment on a client who has returned from colostomy surgery. What action would not be included?

- Take the client's temperature via the rectal route and report a sudden elevation in temperature over 101°F. Explanation: Take the client's temperature by a route other than rectal. Postsurgical assessment would include: - monitoring vital signs - Monitor urine output and the volume of suctioned gastric secretions. If urine output is markedly decreased or less than 500 mL/day, inform the physician immediately. - If an increase in pain and abdominal tenderness or distention occurs, notify the physician immediately.

The nurse is preparing a client for surgery where a Brooke ileostomy will be placed. The nurse assists the client to understand that this type of ostomy handles the passage of stool in what way?

- The client must wear an external pouch and fecal contents drain directly into the pouch. Explanation: A Brooke ileostomy is also known as the standard ileostomy. In this type of procedure, a stoma is formed to drain fecal contents into a pouch. The continent ileostomy has a pouch that is drained with a catheter. An ileoanal reservoir is a type of diversion where the ileum is connected directly to a pouch that was created in the pelvic area and the client ultimately defecates in a normal fashion. A stoma with two openings is known as a loop transverse colostomy and the pouch collects stool and mucus.

The nurse is assessing an older client with an ileostomy who states that the fecal matter coming from the stoma has been at a much greater quantity than usual for the last three days. The nurse is concerned that the client is dehydrated but because of lack of subcutaneous fat, the client's skin is already tented. The nurse will assess the client's fluid status by observing what other part of the client's body?

- Tongue Explanation: The nurse can assess the appearance of the tongue. If the tongue is dry, it indicates fluid deficits

A client underwent a continent ileostomy 2 months ago. How often should the client's reservoir be emptied?

- every 2 to 4 hours Explanation: Initially, the client's reservoir is emptied every 2 to 4 hours. As the capacity of the reservoir increases, typically in about 6 months, the client or caregiver performs the procedure three or four times daily.

A client received a continent ileostomy 10 days ago, and the surgeon is removing the ileal catheter today. How often should the client empty the reservoir?

- every 2 to 4 hours Explanation: Initially, the reservoir is emptied every 2 to 4 hours. As the capacity of the reservoir increases, usually in about 6 months, the client or caregiver performs the procedure three or four times daily.

When an appliance is necessary to collect stool from an ostomy, what primarily determines the consistency of the stool that is collected?

- intestinal placement of the stoma Explanation: The higher the stoma is created within the intestines, the more liquid remains in the expelled stool. The consistency of the stool is determined by the location of the stoma within the intestine.

What would be characteristic of an unhealthy stoma?

- protrusion beyond 2 inches from the skin Explanation: A healthy stoma protrudes from or is just flush with the skin. A healthy stoma may bleed slightly when being cleansed; an unhealthy stoma would have excessive bleeding. An unhealthy stoma would be dull and dry. An unhealthy stoma is dusky blue or black.

If the client is otherwise healthy, which stoma placement would result in formed stool?

- sigmoid colostomy Explanation: Because the stoma from a colostomy is far down the intestinal tract, the stool would be quite firm due to the presence of lower intestine to absorb water from the stool before expulsion.

A client is recovering from the creation of an ileostomy due to complications of a bowel disorder. The client has a history of arthritis and takes daily medication to reduce inflammation. Which medication will the health care provider avoid prescribing?

- sustained-release tablets Explanation: Clients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and sustained-release tablets. These products may pass through without being absorbed.

In which part of the colon would the nurse expect to see a double-barrel colostomy?

- transverse Explanation: A double-barrel colostomy, which is performed most often in the transverse section of the large intestine, contains both a proximal and distal stoma.

The nurse is caring for a client having surgery for a J-Pouch. Which type of rectal drainage should the nurse expect after reviewing the above note written about the procedure in the client's medical record?

- watery stool Explanation: The client is having the second surgery for an ileoanal reservoir where the external stoma of the ileostomy is anastomosed to the distal portion in the gastrointestinal tract. The pouch is connected to the anal cuff for bowel elimination to occur through the rectum. The type of rectal drainage that will occur after this surgery is watery stool. Formed stool is associated with a sigmoid colostomy. Mucus will not be expelled through the rectum after the second surgery for an ileoanal reservoir. Coffee grounds is not used to describe the type of rectal drainage but rather would be used to describe emesis containing blood.

Name the two types of Ostomy's

1. Ileostomy (ileum) 2. Colostomy (colon)

List the 6 causes that would lead a Patient to get an ostomy

1. Inflammatory bowel disorder 2. Rupture of intestine 3. Irreversible 4. Obstruction 5. Compromised blood supply to intestine 6. Cancerous tumor

The nurse is caring for a client who has had a sigmoid colostomy. The client has expressed opposition to using irrigation as a regular way to regulate bowel elimination. What suggestion would help the client achieve this goal?

Increase the amount of fresh and dried fruits that are eaten on a daily basis. Explanation: The client should be instructed to drink prune or fruit juice eat fiber-rich foods and dried fruits perform mild, not vigorous exercise A stool softener, mineral oil or milk of magnesia may be used if the physician approves it.

Define Stoma

opening—exterior abdominal surface