The nurse needs to irrigate the client's sigmoid colostomy. Which interventions does the nurse use to irrigate the colostomy properly? (Select all that apply.)
1. Holds irrigation bag above the ostomy site
2. Places lubricated irrigating cone into stoma
3. Places the client in the right lateral position
4. Uses warm solution to stimulate evacuation
5. Infuses irrigation solution over 60–90 minutes
6. Instructs client to breathe deeply for cramping
1, 2, 4
1. The nurse holds the irrigation bag above the ostomy site to provide positive pres-sure on the irrigation solution and achieve instillation of the fluid into the bowel.
2. The nurse lubricates the cone to prevent stoma trauma.
4. The nurse infuses warm solution into the colostomy to help prevent abdominal cramping.
3. The nurse places the client in the left lateral position to facilitate instillation of the irrigation solution because the solution is most likely to reach the transverse colon to the rectum and thereby provide a better irrigation.
5 and 6. The nurse stops the irrigation for abdominal cramping and allows the pain to subside before continuing with the procedure.
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