Ask the client to remain inactive for 5 minutes. Press the adhesive faceplate from the stomal edge inward Ensure that no air is trapped in the pouch Ensure that there are no holes in the pouch After applying the ostomy appliance, the nurse should ask the client to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. The adhesive faceplate should be pressed from the stomal edge outward to prevent the formation of wrinkles. A small amount of air should also be allowed to be trapped in the pouch; liquid feces will then drain to the bottom of the pouch, placing less tension on it. A client has been brought into the ED via ambulance, reporting acute generalized abdominal pain, nausea, fever, and constipation. The healthcare provider suspects appendicitis, but testing has not been performed yet to make a definitive diagnosis. What will the nurse most likely do while initially caring for this client? Administer a laxative to relieve the client's constipation. Frequently palpate the abdomen to assess for changes that might indicate the onset of a perforation. Perform the test for rebound tenderness. Explain to the client why analgesics are being withheld. Analgesics may be withheld initially to avoid masking symptoms that may affect the diagnosis. Avoid multiple or frequent palpation of the abdomen; there is danger of causing the appendix to rupture. Perform the test for rebound tenderness at the end of the examination because a positive response causes pain and muscle spasm and makes it difficult to complete the rest of the assessment. Do not administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain of feeling constipated. Laxatives and cathartics may cause the appendix to rupture. The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery? High Fowler's Supine with head of bed elevated 15 degrees Sims' left lateral Prone After surgery, the nurse places the patient in a high Fowler’s position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain. The nurse is admitting a patient with a diagnosis of diverticulitis and assesses that the patient has a boardlike abdomen, no bowel sounds, and complains of severe abdominal pain. What is the nurse’s first action?
- Spring '18
- clie nt, nur se, pa tient