The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client?
1. Assess perianal skin.
2. Irrigate the pouch every shift.
3. Maintain the drainage system.
4. Change the bag every 72 hours.
5. Explain the purpose of the system to the client.
Correct Answer: 1, 3, 4, 5
Rationale 1: For the client with a fecal incontinence pouch, the nurse should regularly assess the perianal skin area.
Rationale 2: Fecal incontinence pouches are not irrigated.
Rationale 3: For the client with a fecal incontinence pouch, the nurse should maintain the drainage system.
Rationale 4: For the client with a fecal incontinence pouch, the nurse should change the bag every 72 hours or sooner if there is leakage.
Rationale 5: For the client with a fecal incontinence pouch, the nurse should explain the purpose of the pouch to the client.
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