Chapter 21: Ostomy Care

from TEST BANK FOR NURSING INTERVENTIONS & CLINICAL SKILLS, 7TH EDITION BY PERRY, POTTER. Test Bank with

Chapter 32: Home Care Safety

Multiple Choice

1. The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy. Which information would the nurse include during patient teaching?

a. This is what a new healthy stoma looks like.

b. Any bleeding indicates that a problem is present.

c. Healthy stomas are usually pale pink and flat.

d. There should be very little drainage from the stoma.

ANS: A

The nurse instructs the patient to expect a healthy stoma to be pinkish red, indicating adequate oxygenated blood flow, and slightly puffy because it is new. Since the stoma is highly vascular, there may be a little blood. A pale pink stoma indicates decreased blood flow. The stoma should be raised. New stomas drain and are pouched immediately after being created.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. The patient needs no assistance to perform this procedure within a few days. b. The patient will ask questions about what clothing to wear before discharge. c. The patient touches the stoma while looking at it within the next 2 days. d. The patient’s family learns how to pouch the stoma within 1 week.

2. A patient with a colostomy made as a result of abdominal trauma 4 days ago closes eyes during stoma care. What patient outcome is most important for the nurse to help the patient achieve?

ANS: C

Patients usually need time to adjust to an abrupt body image change and a change in bodily function. Looking at the stoma and touching it would indicate the beginning of adapting to the changes. The patient needs to be able to be independent eventually in caring for his ostomy, but it is not expected that he would be caring for the stoma within a few days. The patient needs to talk about what type of clothing will work with the stoma well before discharge but adjusting to the change in his body must come first.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Evaluation a. Use the measurement guide for a proper fit. b. Extend the skin barrier to cover the incisional area. c. Make a wick from toilet tissue before changing the skin barrier. d. Trim the skin barrier to fit slightly over the stoma margin.

3. The nurse is teaching the patient how to size the skin barrier around the stoma. Which instructions does the nurse include?

ANS: A

The nurse instructs a patient to measure the stoma with the measurement template so the stoma will have enough room to fit and to ensure that there is no excessive pressure on the stoma to impair its blood flow. The nurse instructs the patient to avoid covering the incisional area because it is unnecessary and can interfere with healing if the barrier covers a new surgical incision. Toilet tissue wicks can leave residue on the stoma. If a wick is made to absorb drainage, it should be made using gauze. The nurse avoids extending the skin barrier over the stoma to maintain adequate blood flow to the tissue.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Empty the pouch at least every 4 hours around-the-clock. b. Change the pouch every 3–7 days. c. Empty the pouch when it is at least three-fourths full. d. Change the pouch every other day.

4. The nurse instructs a patient about home colostomy care. What information does the nurse include in patient teaching about caring for the pouch?

ANS: B

The nurse instructs the patient to change the pouch every 3–7 days unless it begins to leak, in which case the patient should change it earlier. The nurse encourages the patient to use the pouch as long as possible, within reason, because ostomy supplies are costly. The pouch is emptied when it is one-half to two-thirds full to prevent it from pulling away from the body. It can be emptied before going to bed and when the patient awakens. The nurse encourages the patient to empty the pouch before it is two-thirds full because a pouch filled to this level is very heavy and more likely to leak.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning a. Formed stool b. Stool that is like thick liquid c. Watery stool d. Semi-formed stool

5. The nurse evaluates the effluent from the patient’s new ileostomy. What does the nurse expect the effluent to look like immediately after surgery?

ANS: C

Stool from an ileostomy can range from thin to thick liquid. Since no food is present, the effluent would be watery. Formed and semi-formed stool is more consistent with colostomy stool. The normal ileostomy stool when food is present is the consistency of a thickened liquid because there is a lot of water in the effluent since most water absorption occurs in the large intestine.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Explore with the patient exactly what her concerns are. b. Tell her when she can start wearing regular clothing. c. Tell the patient that most patients have these feelings. d. Ensure that only female caregivers are assigned to her.

6. The nurse cares for a patient on the fourth postoperative day after an ileostomy. The patient tells the nurse that she doesn’t think she can cope and refuses to look at the ileostomy. What approach by the nurse would be most helpful in this situation?

ANS: A

The nurse needs to find out the patient’s deepest concerns and find support for her. Assuring the patient that others have felt the same way ignores her feelings and concerns. A discussion about appropriate clothing does not address the patient’s deeper concerns. Female caregivers may or may not be available to care for the patient and would not ensure that the patient’s most pressing need is met.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Use soap and warm water for peristomal cleansing. b. Leave the pouch in place for 3–7 days. c. Place several pin holes in the pouch for flatus to escape. d. Use a firm pouching system on a round, hard abdomen.

7. The home-health nurse pouches an ostomy for a patient with serious financial constraints. What would the nurse recommend to the patient about ostomy care?

ANS: B

A pouch is expected to last 3–7 days and does not need to be changed more frequently. Allowing the pouch to remain in place as long as possible saves on the cost of supplies. The nurse helps the patient find community resources for assistance in procuring needed supplies. The nurse avoids using soap for peristomal cleansing because it can leave a residue on the skin, which can impair the protective properties of the skin barrier, leading to skin breakdown. Punching holes in the pouch should be avoided because it allows intestinal gas to drift out of the pouch. The patient is likely to notice the odor and change the pouch to reduce it, incurring unnecessary expense with extra pouch changes. A firm, round abdomen requires a softer, more flexible pouch system to secure the skin barrier.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Document the amount. b. Notify the physician. c. Encourage more fluids. d. Check the skin turgor.

8. The patient’s urinary output from a urostomy is 150 mL in the last 4 hours. What action does the nurse take?

ANS: A

The amount is above the 30 mL/hr minimum for urinary output and is normal. None of the other options is necessary in this situation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “You’ll get up and empty the bag whenever you wake up at night.” b. “We give you a larger pouch to wear at night to hold the extra urine.” c. “We’ll attach a large bedside drainage bag to the outlet of the pouch.” d. “It’s really nothing to worry about until you start eating regular meals.”

9. A patient has a new urostomy because of bladder cancer. The patient asks how to manage “all of this urine” at night. Which response by the nurse is best?

ANS: C

A bedside drainage bag is attached to the pouch outlet, which is opened during the night to allow the urine to drain. It is closed and disconnected if the patient will be up. With this attachment, the patient won’t have to empty the smaller bag overnight. A larger pouch would become heavy and could pull away from the body at night. Urine will begin to flow immediately; thus, telling the patient not to worry is inaccurate and ignores the question.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Document the findings. b. Ask how the patient is measuring the stoma. c. Call the health care provider. d. Rub the stoma to see if it bleeds.

10. The nurse notices that the patient’s stoma is darker than before, purplish in color, and dry. The patient has been taking care of the ostomy independently. What action will the nurse take initially?

ANS: B

The first action is to find out from the patient the technique used for determining the size of the opening for the stoma. If it is too tight, the blood supply to the stoma could be decreased. Information needs to be obtained before documenting or notifying anyone else. Rubbing the stoma may cause injury. Since the stoma should be highly vascular, slight bleeding might be seen when it is cleaned.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Have the patient void into a sterile cup after being cleaned. b. Collect the specimen from a new urine pouch. c. Insert a sterile catheter into the urinary stoma. d. Let urine drip from the stoma into a sterile specimen cup.

11. A patient with a urostomy requires a sterile urine specimen for culture and sensitivity. Which action will the nurse take to obtain the sterile specimen?

ANS: C

The nurse must catheterize the urostomy to obtain a sterile urine sample. A patient with a urinary diversion cannot void. A new urine pouch is clean, not sterile. Letting urine drip from the stoma into a sterile specimen cup does not yield a sterile specimen. The patient’s skin is not sterile, and the urine could irritate the skin.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is educating a patient about care of a stoma after discharge. Which of the following statements indicate a good level of understanding? (Select all that apply.)

a. “Applying gentle pressure with my hand over the skin barrier helps it stick.” b. “I should also use a skin prep such as a paste or adhesive first.” c. “I can get a pouch that absorbs gas odors.” d. “I can access community resources if supplies are too expensive.” e. “I need to change the pouch every 3–7 days.”

ANS: A, C, D, E

The patient will apply a pouch to clean, dry skin without other skin preparations, paste, or adhesives unless there is a specific problem keeping a pouch intact. The adhesives on the skin barriers are pressure and heat sensitive; thus have the patient apply gentle pressure with the hand over the skin barrier for several minutes to facilitate the adherence of the barrier to the skin. Some pouches have effective gas filters that absorb odors and allow for flatus to escape slowly from the pouch through a charcoal filter. Pouches should be changed every 3–7 days. There are community resources the patient can explore if supplies are too expensive.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. “I have been buying sterile gloves to use when changing my pouch.” b. “I have been covering the pouch with saran wrap when I shower.” c. “I empty the pouch directly into the toilet.” d. “I always inspect my skin whenever I change the skin barrier.” e. “I keep the new pouches in the bathroom linen closet.”

2. The home care nurse is visiting a patient who was recently discharged with an ostomy. Which of the following statements require the nurse to provide some additional teaching? (Select all that apply.)

ANS: A, B

The home care nurses should evaluate the patient’s home toileting facilities and ability to position self to empty the pouch directly into the toilet. The patient may shower without covering the pouch. Ostomy care does not require any sterile supplies; however, family caregivers should wear gloves to avoid direct contact with stool. Patients should avoid placing pouches in extremely hot or cold locations because temperature affects barrier and adhesive materials. It is important for the patient to assess the skin under the barrier.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation

Matching

Match the terms with the descriptions below.

a. A stoma that appears dry, black or purple, and does not bleed when washed gently.

b. These keep the ureters from becoming stenosed where they are attached to the ileal conduit.

c. A segment of the small-intestine that is brought up through the abdominal wall.

d. A stoma that is below the skin level on the abdominal wall.

e. A segment of the large intestine that is brought up through the abdominal wall.

1. Stents

2. Colostomy

3. Ileostomy

4. Retracted stoma

5. Necrotic stoma

1. ANS: B DIF: Cognitive Level: Remembering