A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?
“I will empty my pouch when it becomes 1/3 full.”
“I will be careful to take enteric-coated medications.”
“I will change my entire pouch system at least weekly.”
“I will use caution when eating high-fiber foods.”
The Correct Answer is B
Rationale:
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
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Correct Answer is B
Explanation
Rationale:
A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.
B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.
C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.
D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.
Correct Answer is A
Explanation
Rationale:
A. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.
B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.
C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.
D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.