The Ins And Outs Of Ostomy Management
The ins and outs ofostomy management32 Nursing made Incredibly Easy! September/October 2013www.NursingMadeIncrediblyEasy.comCopyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Take away the confusion about types of ostomies andpatient education with case studies on colostomy,ileostomy, and urostomy.By Donna Scemons, PhD, FNP-BC, CNS, CWOCNPresident and Family Nurse Practitioner Healthcare Systems, Inc. Castaic, Calif.Assistant Professor and Coordinator of Family Nurse Practitioner ProgramCalifornia State University Los Angeles, Calif.Ostomy, stoma, colostomy, ileostomy, urostomy, or ileal conduit? Even if these termsare clear to you, they’re confusing for manypatients and family members. In this article,we’ll walk through three patient examplesof colostomy, ileostomy, and urostomy—surgical procedures involving diversion ofeither fecal matter or urine through a stomalocated in the abdominal wall—to help youeducate hospitalized patients after surgeryso they’re prepared to care for their ostomyafter discharge. See Sorting out ostomies andColostomy and ileostomy care for additionalinformation about location, etiology, effluent, and permanence by type of ostomy.Caring for a patientwith a colostomyMs. G, a 67-year-old Black American, is aretired teacher. Her mother, father, and anolder brother were treated for breast and/orbowel cancer and died of their disease. Alladults in Ms. G’s family smoked cigarettesand consumed a diet high in fat and red orprocessed meat and low in fiber. She quit atwo pack/day habit at age 57 when her firstgrandchild was born.Although Ms. G previously had regularbowel habits, for the past 6 months she’shad an elimination pattern of narrow stoolsfollowed by constipation and then ONTACT HOURSA fecal occult blood test was positive ather annual physical exam 2 weeks ago.Diagnostic testing revealed a lesion in thesigmoid colon. Her surgeon suspects shehas colon cancer.Other diseases or conditions that maylead to a colostomy are Crohn disease,intestinal obstruction, perforated diverticula or abscess, intestinal or rectal trauma,rectovaginal fistula, Hirschsprung disease,imperforate anus, necrotizing enterocolitisor other birth defects, and functionalconstipation.Ms. G is scheduled for surgery to removethe lesion and will most likely return fromsurgery with a colostomy. This meansthat the colon will be diverted somewherealong its 5 ft (1.5 m) to form a stoma throughthe abdominal wall. Asking for a moreprecise post-op report will provide thecolostomy location and allow for the mosteffective care plan and patient education.When a malignancy has been removedfrom the colon, the colostomy is usuallylocated in the sigmoid colon. For patientswith more advanced disease, however, thesurgeon may fashion the colostomy inanother section of the colon. The locationof the colostomy determines to a largeextent the consistency and frequency ofthe effluent.September/October 2013 Nursing made Incredibly Easy! 33Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sorting out ostomiesType of ostomy and locationEtiologyEffluent typeTemporary or permanent?Sigmoid colostomyLower left abdomen Cancer of the rectum or sigmoid colon (most common) Bowel obstruction Congenital defects Paralysis TraumaSoft to firm andformedUsually permanent, but maybe temporary in some cases ofabdominal trauma and/or diverticulitisDescending colostomyLower left abdomen Cancer of the rectum orsigmoid colon Bowel obstruction Congenital defects Diverticulitis Paralysis TraumaSoft, semiformed toformedUsually permanent, but dependson etiology and the patient’sclinical conditionTransverse colostomyUpper abdomen, middle or rightside Birth defects Bowel obstruction Cancer (descending orsigmoid colon) Diverticulitis Paralysis TraumaSemiformed; fewdigestive enzymespresent; unpredictableDepends on etiologyAscending colostomyRight abdomen Colon cancer, usuallyright-sided tumors Rarely done becauseileostomy is preferableSemiliquid to liquid;contains highly acidicdigestive enzymesUsually permanent, but dependson etiology, the rationale forostomy creation, and thepatient’s general conditionLoop colostomyUsually in the transverse colonwith proximal (effluent) and distal(mucus) stoma; upper abdomen,middle or right side; patient maypass mucus rectally Trauma More easily done in emergency situationsSemiformed; fewdigestive enzymespresent; mucus fromthe second stomaUsually temporary, but dependson etiology and the patient’sgeneral health, clinical condition, and the rationale for stomacreationDouble-barrel colostomyProximal and distal stoma; distalis mucus fistula Cancer of the rectum orsigmoid colon Bowel obstruction Diverticulitis TraumaSemiformed; fewdigestive enzymespresent; mucus fromthe second stomaUsually temporary but dependson etiology, the patient’s generalhealth, clinical condition, and therationale for stoma creation Ulcerative colitis Familial polyposis Crohn diseaseLiquid; contains highnumber of digestiveenzymesDepends on etiology; may beused as a fecal diversion; if thepatient is being prepared for anIleoanal anastomosis, the ileostomy is temporary for severalweeks before the second surgeryto create the internal pouchCOLOSTOMYILEOSTOMYIleostomyLower right abdomen is mostcommon, but may also be placedin the lower left abdomen; dependent on surgical findings, abdominal condition such as scars, andsurgeon’s preferencecontinued34 Nursing made Incredibly Easy! September/October 2013www.NursingMadeIncrediblyEasy.comCopyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ileoanal anastomosis (alsoknown as J-pouch, pullthrough, or pelvic pouch)Usually in the lower rightabdomen; the patient must havean intact, disease free anus; thebowel is surgically attached to theanus and the patient doesn’t wearan ostomy appliance Ulcerative colitis Familial polyposisLiquid to soft stool;high number ofdigestive enzymes;initially until the pouchis sufficiently stretched,the patient will have 8to 10 stools/day; afterthe pouch is stretched,bowel movements maybe reduced to 4 to 6/dayUsually permanentContinent ileostomy (alsoknown as Kock pouch orBarnett continent ileal reservoir)An option when there’s damage ordisease in the rectum and/or anus Bowel diversion surgeries:ileostomy, colostomy,ileoanal reservoirLiquid to paste-like;contains highernumber of digestiveenzymes than acolostomyUsually permanentUrostomyUsually in the lower rightabdomen Bladder cancer Neurologic dysfunction ofbladder Birth defects Chronic bladderinflammationContinuous urine andsome mucusUsually permanentUreterostomy (rarely done)Surgical placement of uretersdirectly to the right and left abdomen; requires two appliances(one for each stoma) Bladder cancer Neurologic dysfunction ofbladder Birth defects Chronic bladderinflammationContinuous urine andsome mucusTemporary or permanentdepending on etiology and thepatient’s general healthIleal conduitUsually in the lower rightabdomen Bladder cancer Neurologic dysfunction ofbladder Birth defects Chronic bladderinflammation Radiation injuries Spinal cord injuryContinuous urine andsome mucusUsually permanentContinent urostomy (alsoknown as Kock pouch orIndiana pouch)In thin patients, more midlineabove pubic hair; placed higher inolder adults or obese patients Bladder cancer Gynecologic cancer Neurologic dysfunction ofbladder Birth defectsUrine through straightcatheterization every4 to 6 hoursUsually permanentBladder substituteAn internal pouch is surgicallycreated to which ureters areattached; there’s no stoma, thepatient urinates through theurethra Bladder cancer Gynecologic cancerUrine through theurethraUsually September/October 2013 Nursing made Incredibly Easy! 35Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Colostomy andileostomy areused to divertfecal matter.In Ms. G’s case, the colostomy is located inthe sigmoid colon, so her stoma is located onthe left side of the abdomen. Postoperatively,gas followed by effluent from a colostomywill generally start on the third to fifth day.Initially, it may be more liquid and dark redto brown with a mucus consistency as thebowel rids itself of old blood and mucus.After Ms. G resumes her usual activities, theeffluent will likely be the consistency of asemisolid thick paste or more formed. If shehad regular and routine bowel movementsbefore developing cancer, Ms. G may experience more regular effluent with a sigmoidcolostomy.Ms. G’s healthcare provider may prescribecolostomy irrigation to assist in regulatingthe effluent. How long the patient remains inacute care and whether irrigation is prescribed depends on the surgeon. If irrigationis prescribed, it may first be performed athome with the assistance of a home healthcare nurse, depending on how long thepatient stays in acute care. This nurse may ormay not also be a wound, ostomy, and continence (WOC) nurse. Colostomy irrigationmay also be taught by nurses in long-termcare facilities.Irrigation is performed by administeringan enema through the colostomy using acolostomy irrigation set rather than anenema set. Ms. G’s nurse discusses the rationale for colostomy irrigation—the colostomyproduces effluent with no natural control ofthe outflow—and teaches her how to perform the procedure.Ms. G’s nurse educates her about caringfor her stoma, as well as selecting and caringfor the appliances or pouches. The applianceor pouch with which Ms. G leaves surgerywill be used for the first few days or even thefirst week. During this time, the skin barrieror wafer should be changed every 3 to 5days or as needed if leaking occurs.Patient education includes informationabout cleaning the peristomal skin withtepid water alone or with a mild, nondryingsoap. The skin must be patted dry with a36 Nursing made Incredibly Easy! September/October 2013clean dry tissue or cloth before the skin barrier is placed to ensure it sticks and preventsleaking.A key point the nurse discusses withMs. G is that any leaking requires a completechange of equipment—down to the skin—because a leak can’t be patched. The openingin the skin barrier should be fitted aroundthe stoma with 1/16- to 1/8-in distance betweenthe stoma and the barrier.Her nurse also educates Ms. G about thestoma: As a part of her intestine, it shouldgenerally be the same color as the tissue inher mouth. Because it’s a mucous membrane, the stoma has no nerve endings andshould always be moist. The stoma maybleed occasionally; this isn’t unusual unlessbleeding is active (consistent and doesn’tstop). If the bleeding doesn’t stop, Ms. Gshould immediately notify her healthcareprovider.Ms. G needs to learn how and when toempty the pouch. The nurse tells her thatwhenever the pouch is one-third to half full,she should empty it by releasing the tail closure while sitting on the toilet. There are various tail closures in use today, so educationdepends on the type of closure. Emptyingthe pouch helps prevent leaking from theweight of the effluent pulling the barrieraway from the skin.If the patient has an intestinal obstruction, intestinal or rectal trauma, a rectovaginal fistula, a perforated diverticula orabscess, or certain cancers of the colon, thecolostomy may be temporary rather thanpermanent. In some cases, when the surgeon determines that the bowel has healed,a reversal or takedown surgery may bescheduled. Although this procedure is considered surgery, the time in the OR and inpost-op recovery is usually significantly lessthan for a colostomy.Caring for a patientwith an ileostomyMr. Z, a 27-year-old White American, is apsychologist with a history of ht 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Colostomy and ileostomycareA patient with a colostomy or ileostomy wears anexternal pouch over the ostomy site, attached viaa hydrocolloid wafer. The pouch collects fecalmatter, helps control odor, and protects thestoma and peristomal skin. Most disposablepouching systems can be used for 7 days, unlessa leak develops.When selecting a pouching system, chooseone that delivers the best adhesive seal and skinprotection for that patient. Other considerationsinclude the stoma’s location and structure, consistency of the fecal matter, availability and costof supplies, amount of time the patient will wearthe pouch, any known adhesive allergy, and thepersonal preferences of the patient.The best time tochange a pouchingsystem is first thing inthe morning or 2 to 4hours after meals,when the bowel is leastactive. After a fewmonths, most patientscan predict the timethat’s best for them.Ostomy sitesTransverse colostomyAscending colostomyDescending colostomyIleostomySigmoid r/October 2013 Nursing made Incredibly Easy! 37Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
took antibiotics as prescribed and has beenN.P.O. since 10 p.m.Then he explains that the surgeon has toldhim during this first surgical procedure, hiscolon and rectum will be removed, but hisanus and anal sphincter muscles will bepreserved. The surgeon will create a pouchfrom the ileum and connect it to the patient’sanus. Mr. Z will have a temporary ileostomyto allow time for this pouch to heal. Thetemporary ileostomy is an opening to theskin surface that allows collection of fecalmatter in a pouch or ostomy appliance. Heexpects to have this temporary ileostomyfor 8 to 12 weeks.Mr. Z has explored various ileostomypouching systems on the Internet and hasbrought the type he wants to use to thehospital. He says his surgeon agreed touse this type of system as long as thepackaging is sterile. Mr. Z presents thenurse with an unopened box of a wellknown brand oftwo-piece drainableappliances. AcrossDefinitionsthe package are the Ostomy: a surgical procedure used to create an openingwords “sterile untilfor urine and feces to be released from the body Colostomy: a surgical procedure where a portion of the largeopened.”intestine is brought through the abdominal wall to carry stool outLater that day,of the bodyMr. Z has the first Anal anastomosis: a surgery that involves attaching the ileum tosurgery performedthe anus after the entire colon and rectum have been removed, allowinglaparoscopically.the patient to pass stool normally and avoid colostomyHe’s kept in the Ileostomy: the surgical creation of an opening into the ileum, with aCCU for 48 hours,stoma on the abdominal walland transferred to Ileal conduit: the surgical anastomosis of the ureters to one end of athe medical-surgicaldetached segment of ileum, the other end being used to form a stomaunit on the thirdon the abdominal wallpost-op day. During Urostomy: the surgical construction of an artificial excretory openingfrom the urinary tract; a diversion of the urinary flow away from the bladher initial assessder, resulting in output through the abdominal wall; the most commonment after Mr. Z’smethod involves using a portion of intestine to conduct the urine outtransfer, the nursethrough the abdomen and into an external pouch worn for urine collectionfinds his abdomen Stoma: a surgically constructed opening, especially one made in thesoft and nontender,abdominal wall to permit the passage of wastewith an ileostomy Ileal pouch: a surgically created chamber made up of a portion of theon the lower rightlower part of the ileum, the last (lowest) part of the small intestineside. The stoma is Skin barrier or wafer: a pectin-based wafer used to protect the skinred, and aboutfrom irritating drainage100 mL of cloudycolitis since age 18. His twin sister diedfrom toxic megacolon at age 23. His fatherdied from massive gastrointestinal hemorrhage when the patient was age 7, and hismother died 2 years ago from complicationsof diabetes. Mr. Z has no other living relatives, but he does have several friends whoare willing and able to be involved in hiscare. He’s admitted to the surgical floor forthe initial stage of a restorative proctocolectomy, also known as an ileal pouch-analanastomosis.During admission, the nurse inquiresabout the prescribed pre-op bowel cleansingand antibiotic regimen. Mr. Z says he drank1 gallon of polyethylene glycol yesterday as prescribedand is certain hisbowel is thoroughlycleansed. He alsotells the nurse hecheatsheet38 Nursing made Incredibly Easy! September/October 2013www.NursingMadeIncrediblyEasy.comCopyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
serosanguineous effluent is near the tailclosure.Mr. Z has a nasogastric tube and a urinarycatheter in place, and both are functioning.For pain management, Mr. Z has patientcontrolled analgesia, which he uses infrequently. When asked about his pain, he saysit’s less severe than one of his ulcerative colitis attacks, rating it a 3 out of 10 on a 0-to-10pain rating scale. He’s looking forward to arapid recovery and hospital discharge.The following day, active bowel soundsare auscultated, and both the nasogastrictube and urinary catheter are removed. Hispost-op recovery continues, and he beginsto empty his ileostomy appliance while thenurse is at the bedside. During the rest ofhis hospital stay, the nurse provides education about completely changing the ileostomyappliance every 4 to 6 days and as necessary if leaking occurs. The nurse explainsthat the effluent is acidic and will cause achemical burn due to digestive enzymes ifit’s allowed to remain on the skin. Mr. Zhas a high-output ileostomy, with a dailyoutput of 2 L/day, so emptying the appliance up to 8 to 10 times/day is critical tokeeping his peristomal skin intact.Before discharge, Mr. Z can change hisileostomy pouch and explain his diet, medications, and where he’ll obtain additionalostomy supplies. Important educationincludes drinking enough fluid daily toreplace ileostomy losses, chewing all foodthoroughly, and eating foods that thicken theeffluent such as pasta or potatoes withoutfat-filled sauces. He may also discuss withhis healthcare provider the use of medications to thicken the effluent.On the eighth post-op day, Mr. Z isdischarged home and will be followed bythe home health WOC nurse. He’s accompanied by two close friends who’ve alsobeen taught (with the patient’s permission)how to manage his ileostomy, diet, andactivities. They plan on remaining withhim at his home until he’s independent inhis care.www.NursingMadeIncrediblyEasy.comCaring for a patientwith a urostomyMr. S, a 55-year-old Hispanic American, is acomputer programmer with three adultchildren. He had an ileal conduit for bladder cancer 4 days ago. An ileal conduit isthe most common surgical procedure for invasive bladder cancer.During the nurse’s initial assessment, theurostomy pouch, located to the right of theumbilicus, drains cloudy yellow urine withmucus strings into a bedside drainage bag.The nurse notes the presence of ureteralstents in the stoma.Mr. S’s abdomen is soft and tender to palpation, with active bowel sounds. The stomais dark red, about 1 in (2.5 cm) above theskin. The color, location, and size of thisstoma are considered normal. The patientasks the nurse to help him to the bathroom.He disconnects the bedside drainage bagtubing and closes the valve at the end of theurostomy pouch, placing a cap over thebedside drainage tubing. In the bathroom,he places the end of the pouch between hislegs and allows it to completely drain intothe toilet before closing the valve once again.Later that day, the nurse helps Mr. Schange his appliance in the bathroom usinga one-piece urostomy appliance with a skinbarrier constructed for use with urine.(For how to change a two-piece pouchingsystem, see Applying a skin barrier andpouch.) Although his hands shake becausehe’s nervous, he traces a pattern onto theback of the new skin barrier and cuts theopening 1/16-in larger than his stoma. Withthe nurse’s assistance, he removes the oldappliance, using a push-pull technique toreduce skin trauma. Mr. S uses a clean facecloth moistened with water to clean theperistomal skin. Then he places a roll ofgauze at the opening of the stoma to collectthe continuous urine flow while he pats theskin dry with tissue. He quickly removes therolled gauze and secures the new appliance,looking in the mirror for correct placementand smoothing the skin barrier in place.Urostomy isused todivert urine.September/October 2013 Nursing made Incredibly Easy! 39Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Applying a skin barrier and pouchFitting a skin barrier and ostomy pouch properly can be done in a few steps. Shown here is a two-piecepouching system with flanges, which is commonly used.135Measure the stoma using a measuring guide.2Trace the appropriate circle carefully on the back of theskin barrier.Cut the circular opening in the skin barrier. Bevel theedges to keep them from irritating the patient.4Remove the backing from the skin barrier and moistenit or apply barrier paste, as needed, along the edge ofthe circular opening.Center the skin barrier over the stoma, adhesive sidedown, and gently press it to the skin.640 Nursing made Incredibly Easy! September/October 2013Gently press the pouch opening onto the ring until itsnaps into place.www.NursingMadeIncrediblyEasy.comCopyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Safely back in bed, Mr. S asks about a special diet. For a patient with a urostomy,drinking at least eight 8-oz glasses of water/day is most important, and drinking cranberry juice will help keep his urine acidic.Although he can eat garlic, asparagus, andonions, they’ll give his urine a strong odor.The nurse reassures him that the material ofhis pouch will generally contain any odoruntil he empties the urine.During this discussion, Mr. S also asksabout limitations to his physical activity. Hecan gradually resume activity like any postop patient who’s had abdominal surgery,but he shouldn’t engage in contact sportsthat may involve a direct blow to his abdomen. He should avoid heavy lifting until hissurgeon gives approval.patients, or only to those with a complicatedpost-op course requiring the WOC nurse’sexpertise.The nurse’s roleAmerican Cancer Society. Urostomy: a guide. urostomy-intro.Unless the patient needed an emergencysurgical procedure, the ostomy is likelyto have been preceded by some or manyprocedures. The testing and diagnosismay have created confusion and anxietyfor many patients and their families orcaregivers.Some healthcare organizations employWOC nurses, who may have preoperatively marked the preferred site for the stomaand provided patient and family educationthroughout the patient stay. Althoughthese same WOC nurses may follow thepatient with an ostomy from pre-op care tohome health, the nurse who’s responsiblefor caring for a patient with an ostomy isalso responsible for providing patienteducation.Whether the direct care nurse providesostomy care and education depends on thefacility and geographic location of thehealthcare organization. In some facilities,and in some parts of the country, the WOCnurse is a consultant who’s responsible forworking directly with patients during thepre-op phase of care for stomal marking andeducation. In such situations, the WOCnurse may provide direct post-op care to allwww.NursingMadeIncrediblyEasy.comPrepared to careThe three examples presented here represent the more common ostomies encountered in the United States. By being prepared to care for and teach patients likethese, you can help them more easily adjustto the new realities of daily life. Learn more about itAmerican Cancer Society. Colostomy: a guide. /colostomy-intro.American Cancer Society. Ileostomy: a guide. /ileostomy-intro.Work with yourfacility’s WOCnurse to ensureproper patienteducation.American College of Surgeons. Ostomy home skills program. .html.Beck DE, Roberts PL, Saclarides TJ, Senagore AJ,Stamos MJ, Wexner SD. The ASCRS Textbook of Colonand Rectal Surgery. 2nd ed. New York, NY: SpringerScience&Business Media; 2011.Brewer MB. Ileal pouch-anal anastamosis. view.Cancer Research UK. Types of surgery for invasivebladder cancer. surgery-for-invasive-bladder-cancer.Cappell MS. Pathophysiology, clinical presentation, andmanagement of colon cancer. Gastroenterol Clin North Am.2008;37(1):1-24.Carlsson E, Gylin M, Nilsson L, Svensson K, AlverslidI, Persson E. Positive and negative aspects of colostomyirrigation: a patient and WOC nurse perspective. J WoundOstomy Continence Nurs. 2010;37(5):511-516.Cima RR, Pemberton JH. Ileostomy, colostomy, andpouches. In: Feldman M, Friedman LS, Brandt LJ,eds. Sleisenger and Fordtran’s Gastrointestinal and LiverDisease: Pathophysiology/Diagnosis/Management. 9th ed.Philadelphia, PA: Saunders Elsevier; 2010.Deitz D, Gates J. Basic ostomy management, part 1.Nursing. 2010;40(2):61-62.Deitz D, Gates J. Basic ostomy management, part 2.Nursing. 2010;40(5):62-63.MedlinePlus. Total proctocolectomy and ileal-analpouch. 7380.htm.Moore AK, Esquibel KA, Thal W. Ostomy options forclients with ileostomies. Gastroenterol Nurs. 2008;31(6):418-420.September/October 2013 Nursing made Incredibly Easy! 41Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
National Cancer Institute. Colon cancer treatment. olon/HealthProfessional/page10.National Comprehensive Cancer Network. NCCN clinicalpractice guidelines in oncology. http://www.nccn.org/professionals/physician gls/f guidelines.asp.Ostomy Guidelines Task Force, Goldberg M, Aukett LK,et al. Management of the patient with a fecal ostomy:best practice guideline for clinicians. J Wound OstomyContinence Nurs. 2010;37(6):596-598.Turnbull GB. Managing oversight of colostomyirrigation in long term-care. Ostomy Wound Manage.2003;49(10):13-14.Wound Ostomy and Continence Nurses Society. Basicostomy skin care: a guide for patients and health careproviders. http://www.ostomy.org/ostomy info/wocn/wocn basic ostomy skin care.pdf.The author has disclosed that she’s a speaker for ConvaTec.The author and planners have disclosed that they have no financialrelationships related to this article.DOI-10.1097/01.NME.0000432867.93012.55Want moreCE? Yougot it!For more than 99 additional continuing educationarticles related to skin and wound care control topics,go to Nursingcenter.com/CE.Earn CE credit online:Go to http://www.nursingcenter.com/CE/nmieand receive a certificate within minutes.INSTRUCTIONSThe ins and outs of ostomy managementTEST INSTRUCTIONS To take the test online, go to our secureWeb site at http://www.nursingcenter.com/CE/nmie. On the print form, record your answers in thetest answer section of the CE enrollment formon page 56. Each question has only one correctanswer. You may make copies of these forms. Complete the registration information andcourse evaluation. Mail the completed form andregistration fee of 21.95 to: Lippincott Williams& Wilkins, CE Group, 74 Brick Blvd., Bldg. 4, Suite206, Brick, NJ 08723. We will mail your certificatein 4 to 6 weeks. For faster service, include a faxnumber and we will fax your certificate within 2business days of receiving your enrollment form. You will receive your CE certificate of earnedcontact hours and an answer key to review yourresults.There is no minimum passing grade. Registration deadline is October 31, 2015.DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams &Wilkins together by mail and deduct 0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details.PROVIDER ACCREDITATIONLippincott Williams & Wilkins, publisher of Nursing made Incredibly Easy!, will award2.3 contact hours for this continuing nursing education activity.Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.This activity is also provider approved by the California Board of RegisteredNursing, Provider Number CEP 11749 for 2.3 contact hours. Lippincott Williams &Wilkins is also an approved provider of continuing nursing education by the District ofColumbia and Florida #FBN2454.Your certificate is valid in all states.The ANCC’s accreditation status of Lippincott Williams & Wilkins Departmentof Continuing Education refers only to its continuing nursing educational activitiesand does not imply Commission on Accreditation approval or endorsement of anycommercial product.42 Nursing made Incredibly Easy! September/October 2013www.NursingMadeIncrediblyEasy.comCopyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Bowel obstruction Congenital defects Paralysis Trauma Soft to firm and formed Usually permanent, but may be temporary in some cases of abdominal trauma and/or diver-ticulitis Descending colostomy Lower left abdomen Cancer of the rectum or sigmoid colon Bowel obstruction Congenital defects Diverticulitis Paralysis
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