For a client who has returned to the nursing unit after creation of a continent ileostomy (Kock pouch), the action the nurse would include in the plan of care is
A) attach the catheter to straight drainage initially for several days.
B) irrigate the pouch daily with sterile solutions only.
C) provide a permanent appliance and assist the client in application.
D) restrict oral intake until ileal drainage is profuse.

Question

Quizplus · Accepted Answer

During the surgical formation of the Kock pouch, an evacuation catheter is inserted. A skin barrier and special gauze dressing are then applied to hold the catheter in an upright position to avoid stress on the healing nipple valve. It is imperative to avoid distention of the ileostomy reservoir in the early postoperative period because of the pressure that distention would put on the suture line. Thus the Kock pouch is attached to straight drainage initially for several days, then emptied every 2 hours for about 2 weeks.

For a Client Who Has Returned to the Nursing Unit