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Question

Difficulty: MediumBasic Care and Comfort

A client who underwent the surgical creation of a descending colostomy two days ago reports abdominal discomfort and asks for assistance with pouch maintenance before going to sleep. Which nursing action is most appropriate to promote the client's comfort and physical hygiene?

  1. A
    Assist the client into a prone position to apply direct counter-pressure to the abdomen and relieve surgical incisional pain.
  2. B
    Instruct the unlicensed assistive personnel (UAP) to assess the stoma's color and evaluate the integrity of the surrounding peristomal skin.
  3. Empty the ostomy appliance when it is one-third to one-half full to prevent the weight of the effluent from pulling on the skin barrier.Answer
  4. D
    State to the client, 'Why are you so focused on the pouch tonight? Everyone struggles with it at first, but you will get used to it.'

Answer

The most appropriate action is to empty the ostomy appliance when it is one-third to one-half full.
Emptying the ostomy appliance before it becomes too full (typically at one-third to one-half capacity) is a fundamental comfort and hygiene measure. As the pouch fills with effluent and gas, it becomes heavy. This added weight can pull on the adhesive skin barrier, leading to a compromised seal, leakage of acidic stool onto the sensitive peristomal skin, and significant physical discomfort. Maintaining a lighter pouch before sleep ensures the skin remains protected, the seal stays intact, and the client can rest comfortably.

Step-by-Step Solution

1
Identify the client's primary needs based on the clinical scenario.
The client requires comfort measures and ostomy pouch maintenance two days post-surgery.
Understanding the timeline (2 days post-op) highlights the vulnerability of the new stoma and the surgical incision.
2
Evaluate the positioning intervention for safety.
Prone positioning is determined to be unsafe.
Lying on the abdomen places direct pressure on the newly created stoma and incision, which would increase pain and risk tissue damage.
3
Evaluate the delegation intervention for scope of practice compliance.
Delegating the stoma assessment is outside the UAP's scope of practice.
Evaluating stoma color and skin integrity requires specialized nursing judgment and must be performed by the registered nurse.
4
Evaluate the communication approach.
The statement is non-therapeutic and dismissive.
Using 'why' questions induces defensiveness, and telling the client they will 'get used to it' minimizes their current discomfort.
5
Determine the safest and most effective comfort measure.
Emptying the pouch at one-third to one-half capacity is the correct action.
This prevents the appliance from becoming excessively heavy, which protects the skin barrier seal and prevents irritating leaks.

Key Concept

Ostomy Pouch Maintenance and Client Comfort
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Topics

Basic Care and Comfort

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