Fundamentals of Nursing Q 449
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?
A. Prepare to irrigate the colostomy.
B. After assessing the stoma and surrounding skin, notify the surgeon.
C. Assess bowel sounds and administer antiemetic.
D. Administer a bulk forming laxative, and encourage increased fluids and exercise.
Correct Answer: B. After assessing the stoma and surrounding skin, notify the surgeon.
The client has assessment findings consistent with complications of surgery. Providers and nurses should monitor stomas at regular intervals to look for the multiple complications of colostomies as an integrated team approach. Some complications are extremely troublesome to patients, and they come to the hospital with these presentations, but others may be more occult and have to be looked for.
Option A: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Some procedures like irrigation or enema should be avoided in case of stoma prolapse, chemotherapy, pelvic or abdominal radiation treatments, diarrhea-producing medication, or in case of an irregular functioning stoma and may lead to dependence.
Option C: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative.
Option D: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated. The surgeon must call the patient for regular follow up to assess the condition of the stoma and look for any complications and also assess the disease process for which the colostomy was made and also plan for colostomy closure in case of temporary colostomies.