Ch 38 Caring for Clients with a Fecal Diversion

12. The most common complication of an ostomy is a(n): a. obstruction b. hernia c. bleeding episode d. retraction of the bowel

ANS: B A hernia is the most frequent complication of an ostomy and is caused when a loop of bowel pushes up through the muscle next to the stoma and under the skin. This would require surgical correction to repair.

4. A client has just undergone an ileostomy. The semi-liquid intestinal content that continually flow from an ileostomy is called: a. influent b. outfluent c. effluent d. esfluent

ANS: C Effluent is the continuous flow of semi-liquid contents from the stoma.

1. What is the opening called where the colon is brought out through an abdominal incision? a. stoma b. anastamosis c. peristomal d. polyposis

ANS: A A stoma is an opening where the terminal end of the ileum is brought out through an abdominal incision.

15. Preoperatively, an important role of the wound, ostomy and continence nurse is to mark the location of the stoma. This is called: a. sitting of the stoma b. marking the stoma site c. stoma location procedure d. stoma site preparation

ANS: A It is extremely important that the stoma be located in such a position as to facilitate optimal application of an ostomy bag. Either the surgeon or the WOC nurse will mark the location prior to surgery. This is known as siting of the stoma. When doing this the client's abdomen needs to be examined while they are standing, sitting and lying down.

9. What type of drainage would the nurse expect from an ascending colostomy? a. very liquid b. semi liquid c. semiformed d. very formed

ANS: A The drainage from an ascending colostomy is very liquid since most of the colon has been diverted.

2. The nurse has called the client at home to perform some preoperative teaching prior to the client's admission to the hospital for an ileostomy due to severe ulcerative colitis. Which of the below will the nurse review with the client to prevent postoperative infection? a. clear liquid diet 2-3 days prior to OR b. oral osmotic lavages to cleanse bowel c. laxatives to cleanse bowel d. nonabsorbable antiobiotics e. soft diet 2-3 days before surgery f. sitz bath three times a day

ANS: A, B, C, D Prior to surgery, elimination of stool and bacteria from the colon is important to decrease the chances of postoperative infection. The client is placed on a clear liquid diet for two to three days before surgery. Oral osmotic lavages and/or laxatives are administered to cleanse the bowel. Nonabsorbable erythromycin and neomycin antibiotics are given to eliminate bacteria from the colon.

1. What clinical conditions may warrant the need for an ileostomy? a. ulcerative colitis b. familial adenomatous polyposis c. Crohn's disease d. complications of cancer e. diabetes mellitus f. hypotension g. traumatic injury to colon

ANS: A, B, C, D, G A variety of conditions may warrant the need for an ileostomy. These include familial adenomatous polyposis, ulcerative colitis, Crohn's disease, traumatic injury to the large intestines and complications of cancer. Clients with ulcerative colitis or familial adenomatous polyposis are extremely prone to developing colon cancer, especially after the age of forty.

8. A new ostomy client is feeling anxious about the future and performing ostomy care. Which of the following would be appropriate for the nurse to say to the client? a. "Yea, everybody feels that. Believe me, it's no big deal! b. "I sense that you are feeling anxious about learning ostomy care. I'll help you learn all the steps so you'll feel confident when you go home." c. "You'll be just like new in no time! Hang in there!" d. "I think you are overworrying...you know worrying doesn't help the situation!"

ANS: B A client with a new colostomy, whether it is due to colorectal cancer, ischemic bowel syndrome, or traumatic injury to the colon, will experience a certain level of anxiety due to the impact on her lifestyle. The nurse assesses a client with a new colostomy for signs and symptoms of anxiety. The nurse decreases the client's anxiety by providing emotional support, education, and nursing interventions that help the client learn to accept and manage the ostomy, return to her previous lifestyle, and regain a high quality of life

10. Clients with which type of colostomy may have the option for daily irrigations? a. ascending b. descending c. transverse d. double barrel

ANS: B Clients with descending or sigmoid colostomies may experience predictable passage of stool. They often have the option of choosing between performing daily irrigations or allowing natural evacuation to occur. Clients choosing natural evacuation need to wear a collection pouch at all times. Those who select daily irrigations may only need to wear a stoma cap between irrigations.

18. The first step in teaching a client ostomy care is having the client perform which activity? a. assembling ostomy products b. looking at the stoma c. emptying the bag d. cleansing peristomal skin

ANS: B During the first few post-op days, either the WOC nurse or nursing staff will be emptying the client's pouch and changing it when necessary. During these sessions, it is important for the nurse to explain exactly what is being done and to encourage the client to look at the stoma. Each day, post-op teaching increases until the client is able to empty and change pouch on her own.

17. Postoperative, the nurse will need to assess the drainage in a client's ostomy bag. A first sign that peristalsis has returned is the presence of which of the following in the bag? a. mucus b. gas c. stool d. blood

ANS: B Initially, the only drainage in the ostomy may be a small amount of blood mucus as a result of surgical manipulation of the colon. Then gas will fill the bag indicating the beginning of peristaltic return. It is important the nurse empty the bag of flatus to maintain adherence of the appliance to the skin. Within a few days, stool will be present in the bag indicating resumption of normal intestinal activity.

11. What is very important to note on a client's new stoma in the immediate postoperative period? a. blood b. color c. shape d. size

ANS: B On return from surgery, the new stoma is edematous and ranges from deep red to dusky in color. The color of the stoma is checked with a penlight and documented at least once per shift. Color is important because it reveals the status of the blood supply to the stoma. If blood supply to the stoma is inadequate, the stoma will turn black. Notify the physician if the stoma darkens or becomes black. Immediately after surgery there may be a small amount of serosanguineous drainage in the appliance, the stool-collection device. When the appliance is changed and the stoma is cleaned or touched when swollen, a small amount of bleeding may occur. Reassure the client that a small amount of bleeding is normal. Bowel function is checked every shift to monitor for any obstruction or ileus. Bowel sounds, distention, and abdominal tenderness are checked every 4 hours.

3. The surgical union of two hollow tubular body parts is called a(n): a. colon reconnection b. takedown c. anastomosis d. ileostomy

ANS: C An anastomosis is the surgical union of two hollow tubular body parts. An anastomosis is completed after a colon resection where a portion of the colon is removed.

13. An ileostomy client may be at risk for an electrolyte imbalance due to a high output of effluent. Which would the nurse expect the client to need to replace to prevent an electrolyte imbalance? a. fats b. carbohydrates c. potassium d. sodium

ANS: C An ileostomy with a high output of effluent can cause electrolyte imbalances by loss of large amounts of potassium and protein. The client may have difficulty learning to cope with an appliance that is always filling and the need to take in enough fluid, protein, and potassium to replace the lost nutrients.

6. What is the most common reason a colostomy is performed? a. ruptured diverticulum b. traumatic injury to colon c. colorectal cancer d. ischemic bowel syndrome

ANS: C Colorectal cancer is the most common reason a colostomy is performed. Other conditions necessitating this type of procedure are ruptured diverticulum, ischemic bowel syndrome or traumatic injury to the colon. Other than traumatic injury that can occur at any age, these pathological entities usually develop in clients over the age of fifty.

5. A client had a temporary ileostomy and now has returned to the hospital to have the bowel segments reconnected. What procedure would be written on the OR consent form? a. ileostomy restoration b. ileostomy fecal flow c. ileostomy takedown d. ileostomy reconnection

ANS: C In a takedown, the surgeon removes the ostomy and anastomoses (connects) the remaining intestinal segments. Stool now continuously passes through the intestines and out through the anus.

14. Which individual can help the client prepare for the adjustment to life with a fecal diversion? a. client's personal physician b. skin care nurse c. wound, ostomy and continence nurse d. fecal diversion nurse

ANS: C Preparing the client to adjust to life with a fecal diversion cannot be stressed enough. A Wound, Ostomy and Continence nurse (WOC), previously known as Enterostomal Therapy nurses (ET), should visit the client prior to surgery to prepare the client and answer any of her initial questions. Postoperatively, the WOC can assist with ostomy teaching and care.

20. What is the very first step in teaching a client ostomy care? a. foods to prevent blockages b. daily care of the ostomy c. an assessment of ability for self care d. type of effluent expected

ANS: C Prior to discharge the client receives teaching on how to change the appliance, normal stoma appearance, care of peristomal skin and irritations, how to empty and perform daily care of the pouch, expected type of effluent based on stoma location, and foods to avoid to prevent excessive gas, odor, or blockage. It is important to first note the client's ability to perform self care. Involve the family or caregiver in care especially if client is not ready or able to learn or has special needs or conditions (such as blindness, deafness, language barrier, severe arthritis or other disabilities) that limit ability to perform self-care.

19. What important point should the nurse teach the client to avoid peristomal skin breakdown? a. One only needs to examine skin around stoma every 7-10 days. b. Affix the appliance to the skin when it is damp. c. Stress the importance of a properly fitting device. d. The physician only needs to know about bleeding at the stoma.

ANS: C The nurse should instruct the client about the importance of properly fitting appliances and to periodically measure appliance to ensure a proper fit. The nurse should also teach the client to assess the peristomal skin for signs of breakdown and if present report to WOC nurse or MD. Also, the client should assess the stoma for bleeding, edema and discoloration and instruct client to report to MD if any of these conditions.

2. Which client is a candidate for a fecal diversion? a. client with colon polyps b. client with chronic constipation c. client with severe abdominal pain d. client with ulcerative colitis

ANS: D Clients with a diagnosis of ulcerative colitis, Crohn's Disease, familial adenomatous polyposis, colon cancers, diverticulitis or traumatic injuries to the intestines are candidates for a fecal diversion.

7. How are colostomies classified? a. by grade b. by size c. by color d. by location

ANS: D Colostomies are classified according to the location of the stoma, i.e. ascending, transverse, descending or sigmoid. They may also be classified according to the type of stoma created, i.e., whether it is an end, double-barrel, or loop colostomy. Ascending, descending, and sigmoid colostomies are end colostomies. Transverse colostomies are either double-barrel or loop colostomies.

16. The best location for a client's new stoma is: a. near the ribs b. in a scar c. in an abdominal fold d. below the umbilicus

ANS: D Criteria to determine a good location for a client's new stoma include keeping the stoma away from scars, creases or bony landmarks, i.e. ribs, hips and within the sheath of the rectus muscle, locating the stoma below the umbilicus and in a spot where the client can easily see it.