The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)

stoma is shiny and moist

stoma is deep pink

peristomal skin is not reddened or tender

abdomen flat

bowel sounds present 8 to 10 clicks/gurgles per minute

Answer and Explanation

Correct Answer : A,B,C,D,E

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B.   A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C.   The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D.   A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E.   Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

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Correct Answer is B

Explanation

B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.

D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.

A. Notify the physician B. Explain the procedure in simple terms C. Cancel the surgery until the problem is solved D. Witness the client's signature

Correct Answer is A

Explanation

A. This is crucial because informed consent is not just about signing a document; it's about ensuring that the client fully understands the procedure, including the risks, benefits, and alternatives. The physician can then re-evaluate the client's comprehension and provide further clarification if necessary. It is the responsibility of the healthcare team to ensure that the client is making an informed decision.
B. Explaining the procedure in simple terms may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.
C. Cancelling the surgery is not the immediate best action without first attempting to resolve the misunderstanding.
D. Witnessing the client's signature may be part of the nurse's role, but it is essential that the physician is aware of any gaps in the client's understanding to address them appropriately.

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

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Correct Answer is A

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)