A nurse is reinforcing teaching with another nurse about how change an ostomy appliance for a client who has sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

A) Oucher scale: The Oucher scale is a pain assessment tool that is appropriate for children ages 3 to 12 years. It uses a series of photos depicting facial expressions that range from no pain to extreme pain. While useful for older children, it is not the most appropriate choice for an 8-month-old infant.

B) Visual Analog scale: The Visual Analog scale is typically used for children and adults who are able to understand and use numerical ratings or visual representations of pain. Since an 8-month-old infant is unable to verbally communicate or use this scale, it would not be suitable for evaluating their pain.

C) FLACC scale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who are unable to verbally communicate their pain. It is ideal for assessing the pain levels of infants, as it evaluates observable behaviors like facial expressions, leg movement, and crying, which are indicators of pain in nonverbal children.

D) FACES pain scale: The FACES pain scale is typically used for children as young as 3 years old, but it requires the child to be able to identify and select facial expressions that correspond to their pain. An 8-month-old infant would not be able to engage with this scale, as it requires some cognitive development and understanding of emotional expressions.

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.