ATI – Ostomy Care – Flashcards
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A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first? Measure the stroma Cover the stroma with gauze Remove the backing on the skin barrier Cleanse the stoma and the peristomal skin
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Cleanse the stoma and the peristomal skin To facilitate the nurse's assessment of the stoma and the peristomal skin, the nurse must remove any effluent adhering to the area.
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A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to Apply hydrocortisone cream to the skin when changing the appliance Empty the pouch when it is no more than half full Wash the peristomal skin frequently with deodorizing soap and water Choose a time shortly after a meal for replacing the pouch
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Empty the pouch when it is no more than half full Waiting until the pouch is more than half full increases the risk of leakage. Ileostomy effluent is irritating to peristomal skin, so patients should replace the pouch when it is one third to one half full. Patients should avoid the use of soap, especially oil or lotion based soaps. They leave a residue that can interfere with pouch adhesion and increase the risk of leakage. They should cleanse the skin and warm tap water. For times when soap is essential and if their provider allows it, they should only use a mild, pH balanced soap.
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A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching? Irrigate both stomas periodically to promote drainage Tape a dry gauze pad over the distal stoma to collect drainage Change the proximal stroma's appliance every other day Expect liquid to drain from both stomas
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Tape a dry gauze pad over the distal stoma to collect drainage The distal stoma (also called a mucous fistula) secretes mucus; it does not drain feces. A dry gauze is usually sufficient. With a double barrel colostomy, irrigation might not be necessary at all. If it is, it would only apply to one stoma, not both. Ostomy appliances remain in place for up to 7 days and do not need to be replaced every other day.
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A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is a cecostomy a loop colostomy an ileostomy a decending colostomy
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an ileostomy After removing the entire large intestine and the rectum, the surgeon will create an ileostomy to divert feces from the small intestine to the abdominal surgace and into an ostomy pouch. A cecostomy is a surgical opening created in the cecum, the first section of the large intestine, with an opening to the abdominal wall for diversion of feces. This is not possible if the entire large intestine is removed. A loop colostomy involves a large and usually temporary stoma the surgeon creates by pulling a loop of intestine onto the abdominal wall and creating two openings in the loop. This is not possible if the entire large intestine is removed. A descending colostomy is created when the surgeon removes a portion of the descending colon and uses the remaining section to create a stoma on the outer surface of the abdomen. This is not possible if the entire large intestine is removed.
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A nurse is obtaining a health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited social activities. 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
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Consume foods that are low in fiber content Foods low in fiber help thicken the stool; examples include rice, noodles, white bread, cream cheese, lean meats, fish, and poultry. Mineral oil produces laxative action by lubricating the stool and reducing water absorption from the stool. This will not relieve diarrhea. Buttermilk and cranberry juice can help control oder, but they do not relieve diarrhea.
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While the nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following 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
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Push the skin away from the barrier while removing it Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to adhesive. If the patient is having difficulty with the initial release of the barrier, it may help if she starts in one corner and gently pulls across the stoma while pushing the skin away from the barrier. Lifting the skin from both sides at once will pull directly on the dermis and possibly traumatize the skin. Rolling the skin barrier end over end will pull directly on the dermis and possibly traumatize the skin.
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A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is a Kock's pouch an ileal conduit a cutaneous ureterostomy a nephrostomy
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a Kock's pouch This is a continent ileal bladder conduit that does not require an external drainage collection device because the patient self-catheterizes every 2 to 4 hours to remove urine. The device will control the patient desires. An ileal conduit is a passageway for urine to flow from the kidneys to the outside of the body. With this type of diversion, urine flows as it is produces, so the patient will not be able to control it. A cutaneous ureterostomy allows urine to flow from a ureteral opening to the outside of the body. Urine flows through the stoma as it is produces, so the patient will not be able to control it. A nephrostomy allows urine to flow from the kidney to the outside of the body. Urine flows through the stoma as it is produced, so the patient will not be able to control it.
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A nurse is teaching a patient how to apply an extended wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? Use an oil based lotion on the peristromal area Apply the skin barrier while the skin is slightly moise Leave the residue from the previous appliance on the skin Press gently around the barrier for 1 to 2 minutes
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Press gently around the barrier for 1 to 2 minutes The pressure sensitive tackifiers and heat sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.
