The nurse is caring for a postoperative patient who had a ...

[nramada]

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions may the nurse delegate to the nursing assistant? (Select all that apply.)
 
  a. Gently cleaning the stoma with warm water and a washcloth.
  b. Assessing the stoma and incision for signs of infection or ischemia. c.
  Obtaining needed supplies from the clean utility room.
  d. Teaching the patient how to care for the ostomy after discharge.
  e. Determining which type of ostomy appliance to use.
  f.
  Application of skin protectant to the area surrounding the stoma.

Question 2

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?
 
  a. The patient will remain continent with no perineal skin breakdown.
  b. The patient will state satisfaction with use of gait belt for toilet transfers.
  c. The patient will regain ability to pull up clothing after using the toilet.
  d. Privacy will be provided once the patient is properly positioned on the toilet.

[chereeb]

Answer to Question 1

ANS: A, C, F
The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain needed supplies, and apply skin protectant. The nurse is responsible for assessment, teaching, and determining which ostomy appliance to use.

Answer to Question 2

ANS: A
The highest priority goal for this patient is continence with no perineal skin breakdown to maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to pull up clothing are less important. Privacy is an intervention to be performed by the staff rather than a goal for the patient.

[nramada]

TYSM

[kthug]

Gracias!