A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.

Choice A rationale:

"I will notify my doctor if the stoma starts to look purple" indicates an understanding of the importance of monitoring the colostomy site for signs of compromised blood flow or ischemia. A purple or bluish color of the stoma may suggest reduced blood supply, which is a critical concern and should be reported promptly to the healthcare provider.

Choice B rationale:

"I should expect my stool to be formed" is incorrect. In a colostomy, the type of stool output will depend on the location of the colostomy and the surgical procedure performed. Stool consistency can vary, and it may be formed or semi-formed depending on the individual and the specific situation. Expecting formed stool may not always be accurate.

Choice C rationale:

"I will no longer be able to eat nuts" is not necessarily true for all individuals with a colostomy. While some people may experience digestive difficulties with certain foods, including nuts, it is not a universal rule. Dietary restrictions should be discussed with a healthcare provider or a registered dietitian based on the individual's specific condition and needs.

Choice D rationale:

"I will irrigate the colostomy every day" is not a recommended practice for all colostomy patients. Colostomy irrigation is a procedure that may be performed by some individuals with descending or sigmoid colostomies to regulate bowel movements. However, it is not necessary or appropriate for all colostomy patients. The need for colostomy irrigation should be determined by the healthcare provider and discussed with the patient as part of their individualized care plan.