NCLEX-PN

In addition to education, nurses are responsible for the ongoing care of clients with ostomies. This care encompasses various interventions tailored to the specific type of ostomy: ●​ Monitoring the Ostomy Site: Regular assessment and observation of the ostomy site are crucial to detecting any changes or issues that may arise. ●​ Maintaining Patency: Ensuring that the ostomy remains open and functional is essential. This may involve checking for obstructions or blockages and taking appropriate action to maintain patency. ●​ Preventing Complications: Proactive measures are taken to prevent complications and side effects associated with the ostomy. This includes addressing issues like infection, skin irritation, and leakage. For clients with enteral ostomies , such as those discussed in the sections on "Administering Enteral Nutrition Through Tube Feedings" and "Addressing Side Effects and Complications of Tube Feedings," nurses are actively involved in the management of nasointestinal, nasogastric, nasojejunal, nasoduodenal, jejunostomy, gastrostomy, and percutaneous endoscopic gastrostomy (PEG) tubes. Responsibilities include: ●​ Surgical Entry Site Care : Monitoring and caring for the surgical entry site to prevent infection or other complications. ●​ Tube Patency : Ensuring the tube remains unobstructed and functional. ●​ Placement Verification: Validating that the tube is correctly positioned to deliver feeds effectively and safely. ●​ Intake and Output Monitoring : Measuring and tracking the client's fluid intake and output. ●​ Feeding Administration : Administering tube feedings and evaluating the client's response, including assessing for complications and measuring residual volume. Similarly, for clients with colostomies (transverse, descending, ascending, sigmoid) and urinary diversion ostomies (ileal conduit, neobladder, Miami pouch, Indiana pouch, nephrostomy), nurses are responsible for: ●​ Surgical Entry Site Care : Monitoring and maintaining the health of the surgical entry site. ●​ Ostomy Patency : Ensuring that the ostomy remains open and functioning correctly. ●​ Intake and Output Monitoring : Measuring and recording fluid intake and output. ●​ Complication Assessment : Evaluating clients for potential complications such as necrosis, stomal retraction, stomal stenosis, infection, urinary tract infections, renal calculi, and other issues. For clients with tracheostomies , nurses provide care by:

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