The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply. The newly hired nurse
The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply. The newly hired nurse
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Gastrointestinal
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
Application
Explanation
Choice B is correct. This action is incorrect and requires follow-up. Moisturizing soap should not be used on the peristomal skin as it may prevent the wafer from adhering to the skin. Mild soap is the recommendation.
Choice D is correct. This action is incorrect and requires follow-up. Sterile gloves are not used to provide ostomy care. Using sterile gloves would be a waste of resources. Regular clean gloves are used.
Choice E is correct. This action is incorrect and requires follow-up. Isopropyl alcohol is drying to the skin and irritates it. This makes the skin's integrity more likely to become impaired. This should not be used on peristomal skin.
Choice A is incorrect. The pouch should be emptied when it is one-third to one-half full. This action is correct and does not require follow-up.
Choice C is incorrect. A reddish or pink moist stoma indicates adequate perfusion and is normal. Stomas that appear purple, dry, and black require follow-up with the physician because this is unexpected. This action is correct and does not require follow-up.
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4 Key Topics
Care of Ostomies
9.5 Elimination & Urinary Management
Ostomies
11.3 Surgical Drains & Tubes
Additional Info
✓ After a colostomy is established, it usually begins to produce stool within two to three days following surgery.
✓ The stoma should be reddish-pink and moist.
✓ The appliance (device) should be changed every three to five days.
✓ The pouch should be emptied when it is one-third to one-half full.
✓ Skin care is essential, and the peristomal skin should be inspected frequently for breakdown.
✓ The surrounding skin should be cleaned with mild soap and water. Then, it should be patted dry.
✓ Stoma powder/paste may be used on clean skin to promote adherence with the wafer.
✓ Assess the client's psychosocial readiness for performing self-care.
