Author Question: The nurse is providing ostomy care for a client with a colostomy. Which assessment findings would ... (Read 108 times)

silviawilliams41 · **on:** Jun 25, 2018

The nurse is providing ostomy care for a client with a colostomy. Which assessment findings would the nurse report to the health care provider if noted during the procedure? Select all that apply.

1. No change in stoma size
2. A stoma that appears dry and grey in color
3. The presence of skin irritation
4. The amount of drainage
5. The odor of the drainage

Question 2

The nurse is caring for a client with a newly created ostomy. After changing the ostomy appliance, which items will the nurse include when documenting the procedure? Select all that apply.

1. How the drainage was disposed
2. Quantity of drainage recorded on output record
3. Any client participation in the procedure
4. Assessment of stoma and skin around the stoma
5. The odor of the drainage

nothere · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2,3

The nurse would report abnormal assessment findings to the health care provider if noted when providing ostomy care to the client. Findings that are abnormal include a stoma that is dry and grey in color, as this indicates circulatory impairment, and the presence of skin irritation. No change in the size of the stoma is a normal finding that does not require reporting to the health care provider. The amount of drainage is documented but not reported unless there is a problem. Odor is not reportable and is only documented if a change is noted.

Answer to Question 2

Correct Answer: 2,3,4

The nurse should document how much drainage was emptied, the client's involvement in the procedure, and the assessment of both the stoma and the skin around the stoma. The disposal of the drainage would not need to be documented. The odor would only be documented if it were unusual.