Term
| When administering an enema, why should the nurse lubricate about 5 cm/2 inches of the rectal tube? |
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Definition
| Lubrication facilitate insertion through the sphincter and minimizes trauma. |
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Term
| When administering an enema, why should the nurse run some solution through the connecting tubing of a large volume enema set and rectal tube to expel any air? |
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Definition
| Air instilled into the rectum although not harmful, causes unnecessary distention. |
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Term
| When administering an enema, why should the nurse assist the adult client to a left lateral position, with the right leg as acutely flexed as possible? |
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Definition
| This position facilitates the flow of solution by gravity into the sigmoid and descending colon, which are on the left side. Having the right leg acutely flexed provides for adequate exposure of the anus. |
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Term
| When administering an enema, why should the nurse lift the upper buttock for clients in the left lateral position? |
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Definition
| This ensures good visualization of the anus. |
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Term
| When administering an enema, why should the nurse insert the tube smoothly and slowly into the rectum, directing it toward the umbilicus? |
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Definition
| The angle follows the normal contour of the rectum. Slow insertion prevents spasm of the sphincter. |
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Term
| When administering an enema, why should the nurse insert the tube 7 to 10 cm/3 to 4 inches? |
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Definition
| Because the anal canal is about 2.5 to 5 cm/1 to 2 inches long in the adult, insertion to this point places the tip of the tube beyond the anal sphincter into the rectum. |
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Term
| When administering an enema, why should the nurse ask the client to take a deep breath, then run a small amount of solution through the tube if resistance is encountered at the internal sphincter? |
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Definition
| This relaxes the internal anal sphincter. |
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Term
| When administering a low enema, why should the nurse hold or hang the solution container no higher than 30 cm/12 inches above the rectum? |
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Definition
| The higher the solution container is held above the wrecked him, the faster the flow and the greater the force, pressure, in the rectum. |
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Term
| When administering a high enema, why should the nurse hang the solution container about 45 cm/18 inches above the rectum? |
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Definition
| The fluid must be instilled farther to clean the entire bowel. |
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Term
| When administering an enema, why should the nurse administers the fluid slowly, lowering the container or clamping the flow for 30 seconds, then restarting it at a slower rate if the clients complains of fullness or pain? |
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Definition
| Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution. |
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Term
| When administering an enema, Why should the nurse ask the client to remain lying down? |
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Definition
| It is easier for the client to retain the enema when lying down then when sitting or standing, because gravity promotes drainage and peristalsis. |
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Term
| When changing a Bowel diversion ostomy appliance, why should the nurse assess the used appliance for leakage of stool? |
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Definition
| Stool can irritate the peristomal skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse asked the client about any discomfort at or around the stoma? |
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Definition
| A burning sensation may indicate breakdown beneath the faceplate of the pouch. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse assessthe fullness of the pouch? |
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Definition
| The weight of an overly full bag may loosen skin barrier and separate it from the skin, causing the stool to leak and irritate the peristomal skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse avoid times close to meal or visiting hours? |
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Definition
| Ostomy odor and stool may reduce appetite or embarras the client. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse avoid times immediately after meals or the administration of any medications that may stimulate bowel evacuation? |
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Definition
| It is best to change the pouch when drainage is least likely to occur. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse assist the client to a comfortable sitting or lying position in bed or preferably a sitting or standing position in the bathroom? |
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Definition
| Lying or standing positions may facilitate smoother pouch application, that is, avoid wrinkles. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse empty the contents of a drainable pouch before removing the pouch? |
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Definition
| Emptying before removing the pouch prevents spillage of stool onto the clients skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse hold the clients skin taut while peeling the skin barrier off slowly? |
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Definition
| Holding the skin taut minimizes client discomfort and prevents abrasion of the skin. |
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Term
| When changing a Bowel diversion ostomy appliance, why should the nurse check agency policy on the use of soap? |
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Definition
| Soap is sometimes not advised because it can be irritating to the skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse not use deodorant or moisturizing soap if soap is allowed? |
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Definition
| They may interfere with the adhesives in the skin barrier. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse dry the area thoroughly by patting with a towel? |
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Definition
| Excess rubbing can abrade the skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse place a piece of tissue or gauze over the stoma, and change it as needed? |
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Definition
| This absorbs any seepage from the stoma while the ostomy appliance is being changed. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse make the opening no more than 1/8 to 1/4 inch larger than the stoma? |
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Definition
| This allows space for that stoma to expand slightly when functioning and minimizes the risk of stool contacting peristomal skin. |
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Term
| When changing a bowel diversion ostomy appliance, and using a one piece pouching system, why should the nurse center the one piece skin barrier and pouch over the stoma, gently pressing it onto the clients skin for 30 seconds? |
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Definition
| The heat and pressure help activate the adhesives in the skin barrier. |
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Term
| When emptying a drainable ostomy pouch, why should the nurse empty the pouch when it is 1/3 to 1/2 full of stool or gas? |
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Definition
| Emptying before it is overfull helps avoid breaking the seal with the skin and stool then coming in contact with the skin. |
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Term
| When changing a bowel diversion ostomy appliance, why should the nurse reinforced the teaching each time that care is performed? |
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Definition
| Client learning is facilitated by consistent nursing interventions. |
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