The nurse is performing colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?
A. Notify the physician
B. Stop the irrigation temporarily
C. Increase the height of the irrigation
D. Medicate for pain and resume the irrigation
Correct Answer: B. Stop the irrigation temporarily.
If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Have the colostomy patient sit on or near the toilet for about 15 to 20 minutes so the initial colostomy returns can drain into the toilet. (If the patient is on bed rest, allow the colostomy to drain into the bedpan.)
Option A: The physician does not need to be notified. Unless contraindicated or otherwise ordered by the physician, it is best to establish a routine of daily irrigation in accordance with the patient’s former bowel habits.
Option C: Increasing the height of the irrigation will cause further discomfort. Hold the enema can approximately 12 inches above the bed and allow the solution to flow in slowly to avoid painful cramps usually caused by too rapid flow.
Option D: Medicating the client for pain is not the appropriate action in this situation. If cramping occurs, slow down the flow rate and ask the patient to deep breathe until cramps subside. Cramping during irrigation may indicate that the flow is too fast or the water is too cold.
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