Nurse Intervention Identification for Ileostomy Care
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The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.
Day 1:
Abdomen soft, nondistended.
Ileostomy present. Stoma is red.
Stoma draining brown liquid stool.
Client will not look at stoma.
Client states they are not interested in learning about stoma care.
Day 2:
Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
Stoma with small amount of bleeding noted during cleaning.
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Step by Step Written Solution
In this clinical scenario, we are reviewing a client's medical record after an ileostomy to identify which findings require nursing intervention.
Nursing Assessment: Identifying Interventions
Let's evaluate the Day 1 notes first. The description of the abdomen as soft and nondistended is a normal finding and does not require intervention.
Day 1 Assessment
- Abdomen soft, nondistended (Normal)
- Stoma is red (Normal)
- Draining brown liquid stool (Normal)
A fresh stoma is expected to be red, and brown liquid stool is normal for an ileostomy. However, we see two psychological indicators that need attention.
The client refusing to look at the stoma and showing no interest in learning care indicates a struggle with body image and coping. These findings require emotional and educational intervention.
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