Health Promotion and Maintenance Q 83
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
Correct Answer: B. Keep the irrigating container less than 18 inches above the stoma.”
This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.
Option A: The client must turn on the appropriate side to allow the nurse to do the procedure without difficulty.
Option C: Ask the physician how much water is needed to irrigate.
Option D: Cramping during an irrigation may mean that the water is too cold, the irrigation bag is too high, or the water is going too fast. Clamp off the tubing if this occurs.