A nurse is assisting with preparing a presentation on heart health at a community center for a group of clients. Which of the following actions should the nurse recommend to facilitate learning?

ANSWERED:

Day 1:

• Abdomen soft, nondistended.
• Ileostomy present. Stoma is red.
• Stoma draining brown liquid stool.
• Client will not look at stoma
• Client states they are not interested in learning about stoma care.

Day 2:

• Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
• Stoma with small amount of bleeding noted during cleaning.

Rationale:

Findings requiring intervention

Client will not look at stoma: This indicates potential emotional distress, denial, or difficulty adjusting to the ileostomy. The nurse should address these concerns by providing emotional support and encouraging gradual acceptance of the stoma through education and therapeutic communication.

Client states they are not interested in learning about stoma care: A lack of interest in learning stoma care poses a barrier to self-care and independence. The nurse should explore the client’s feelings, provide gentle encouragement, and offer step-by-step guidance to build their confidence.

Skin surrounding stoma reddened and has small open areas: Redness and open areas suggest irritation or breakdown of peristomal skin, likely due to improper pouch application or leakage. The nurse should assess the fit of the ileostomy pouch, recommend barrier creams, and consult a wound care specialist if needed.

Findings not requiring intervention

Abdomen soft, nondistended: This finding is normal and does not indicate any issues requiring intervention.

Stoma is red: A healthy stoma is typically moist, red, and similar in appearance to the inside of the mouth. This finding is expected.

Stoma draining brown liquid stool: Brown liquid stool is a normal output for an ileostomy and does not require intervention.

Stoma with small amount of bleeding noted during cleaning: Minimal bleeding from the stoma is common during cleaning or manipulation, especially early postoperatively. This is generally not a concern unless the bleeding is excessive or persistent.

A. Rinse the client's dentures in hot water: Hot water can cause dentures to warp.

B. Place the client's dentures on a washcloth in a sink: A washcloth can help prevent dentures from breaking if they fall and prevents damage.

C. Clean the client's dentures with regular toothpaste: Regular toothpaste can be abrasive and damage the dentures. Denture-specific cleaners should be used.

D. Remove the client's dentures with a moist glove: A moist glove is not necessary for removing dentures. Dentures should be removed with clean, gloved hands if needed.