Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

This statement shows that the client understands the importance of monitoring the color of the stoma and seeking medical attention if any concerning changes occur. A purple or dark discoloration of the stoma can indicate inadequate blood supply to the area, which requires immediate medical evaluation.

"I will irrigate the colostomy every day." Colostomy irrigation is not typically done every day. It is a procedure used for some individuals with specific types of colostomies to establish a regular bowel movement pattern. The frequency and need for colostomy irrigation should be discussed and determined with the healthcare provider.

"I should expect my stool to be formed." Depending on the location and type of colostomy, the consistency of stool can vary. In the case of an ascending colostomy, the stool is usually liquid or semi-liquid because it is closer to the beginning of the large intestine. Expecting formed stool with an ascending colostomy would not be accurate.

"I will no longer be able to eat nuts." The ability to eat nuts or any other specific foods will depend on individual tolerance and the advice of a healthcare provider. In general, having a colostomy does not mean that all foods need to be eliminated from the diet. A well-balanced and varied diet can still be maintained with appropriate consideration for individual preferences and any dietary restrictions based on the specific situation.

A.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

B.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.