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OST:581 Quiz 3B
Terms in this set (16)
The patient has a diagnosis of Caput Medusae. You would expect to see protuberant veins in the peristomal field which are caused by?
Portal hypertension causes varices in the alcoholic or patient with liver disease
And incarcerated bowel is an emergent complications associated with?
Peristomal hernia which may contain a loop of bowel in the herniation. If the mesentery of the segment bowel is compromised, ischemia to segment can develop. When the pt has peristomal hernia teach s/s of ischemic bowel (abd pain, n/v, change in stomal color). contact MD immediately.
Pt has a permanent ileostomy, you note ulceration at 9o'clock in peristomal area 7 mm from base of the stoma. The ulcer is producing fecal material. What is this describing?
Most effective pouching technique for a patient with ileostomy and small fistula open on the skin about 5 mm from the base of the stoma is to?
Resize the stoma opening in the pouch to include the fistula opening.
Patient has enterocutaneous fistula you plan to pouch. What for criteria will be essential when selecting a patching system?
Volume of effluent, size of fistula opening on the skin, odor, need for access
MEST is a leading cause of Perry stomal skin breakdown. What describes this?
Inflammation and erosion of the skin adjacent to the stoma
18 hrs After the creation of end stoma. nurse notes stomal mucosa is black and flaccid. What would be the appropriate assessment and intervention's?
Remove the stoma and pouch and gently rub the stoma to note any surface bleeding. Notify surgical service and prepare to examine the stoma using a small, lubricated, glass tube and flashlight.
The nurse is changing a pouching system and doing a teaching session for a new patient. Upon pouch removal a separation of mucocutaneous junctures observed. What would you tell the nurse about why he's complication may occur?
Most likely occurred b/c the pt has been on corticosteroids preop.
Your pt is seen for f/u and c/o pouch leakage and extreme pain in peristomal area. Upon exam you aeee a reddish-purple (violaceous) discoloration with painful open lesions around the stoma. What are you looking at?
An important factor to teach nurses who care for a patient with Gastrostomy tube is to?
Stabilize the two, one of the leading causes of tubes my grading and leaking is that the tube is not being stabilized.
Which of the following interventions would prevent a Gastrostomy tube from clogging?
Only giving liquid form of medications
You are teaching a patient what they Gastrostomy tube that has a balloon. You tell the patient to do which of the following?
Check the balloon volume once a week. Checking balloon volume weekly ensures that the correct amount of fluid is in the balloon. If the amount is less than indicated, fluid should be instilled to correct amount and documented. Fluid can evaporate or the balloon can develop a slow leak over time.
A patient is having a large amount of leakage around a Penrose drain with saturation twice a shift. Surgeon ask you to evaluate and treat the red skin. Best action by the nurse is to?
Apply ostomy pouch with integrated skin barrier.
What is the name of the radiographic study done one investigating the origin of an enterocutaneous cutaneous fistula?
Which other following products can be used to protect the skin around a fistula
Skin barrier powder or wafer.
One of the important features of an endoscopy Gastrostomy procedure, compared to a surgically placed gastrostomy, is that the endoscopy Gastrostomy procedure allows feeding to occur:
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