Ostomy Care
A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? Measure the stoma. Cover the stoma with gauze. Remove the backing on the skin barrier. Cleanse the stoma and the peristomal skin.
Cleanse the stoma and the peristomal skin. The first action the nurse should take is to remove any effluent adhering to the stoma and the peristomal skin to facilitate the assessment of the area.
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. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? Consume foods that are low in fiber content. Take an ounce of mineral oil twice a day. Add buttermilk and cranberry juice to the diet. Increase water intake to 3 to 3.5 L per day.
Consume foods that are low in fiber content. The nurse should recommend that the client consume foods low in fiber to help thicken the stool. Examples of low-fiber foods include rice, noodles, white bread, and cheese.
A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? Cecostomy Loop colostomy Ileostomy Descending colostomy
Ileostomy After removing the entire large intestine and the rectum, the provider will create an ileostomy to divert feces from the small intestine to the abdominal surface and into an ostomy pouch.
A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? Use an oil-based lotion on the peristomal area. Apply the skin barrier while the skin is slightly moist. Leave the residue from the previous appliance on the skin. Press gently around the barrier for 30 seconds to 1 min.
Press gently around the barrier for 30 seconds to 1 min. The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.
A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? Lift up on both sides of the skin barrier simultaneously. Release one corner of the barrier and pull it quickly over the stoma. Push the skin away from the barrier while removing it. Gently roll the barrier end-over-end across the stoma.
Push the skin away from the barrier while removing it. If the client is experiencing pain with the initial release of the barrier, the nurse should suggest removing the barrier by starting in one corner and gently pulling it across the stoma while pushing the skin away from the barrier. This technique can help prevent skin stripping.
A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary eliminations? Kock's pouch Ileal conduit Cutaneous ureterostomy Nephrostomy
Kock's pouch A Kock's pouch is a continent ileal bladder conduit that does not require an external drainage collection device because the client self-catheterizes every 2 to 4 hr to remove urine. This device will allow the client to have some control over urinary elimination.
A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? Apply hydrocortisone cream to the skin when changing the appliance. Empty the pouch when it is less than half full. Wash the peristomal skin frequently with deodorizing soap and water. Choose a time shortly after a meal for replacing the pouch.
Empty the pouch when it is less than half full. The nurse should instruct the client to empty the pouch when it is between 1/3 to 1/2 full because waiting to empty the pouch until it is more than 1/2 full increases the risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin.
A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following info should the nurse include in the teaching? Expect the effluent from the sigmoid colostomy to be loose and continuous. Use irrigation to help establish a regular bowel pattern. Change the stoma's appliance every other day. Expect effluent from the newly created stoma within 24 hr after surgery.
Use irrigation to help establish a regular bowel pattern Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance.
