Medical Surgical Crohn’s vs Ulcerative Colitis #4

Question

The nurse is caring for a client post bowel diversion surgery with a colostomy. In the first 24 hours, which assessment finding should the nurse report immediately?

Answers

  1. Abdominal distention
    • Rationale:

      This answer is not correct since it is not the priority assessment. Some abdominal distention post-op is normal, but should be reported to the healthcare provider.

  2. Incorrectly fitted faceplate.
    • Rationale:

      This answer is not correct because a correctly-fitting faceplate can be applied by the nurse and does not need to be reported. The opening of the faceplate should be ⅛ inch larger than the stoma for an accurate fit.

  3. Blue appearance to the stoma.
    • Rationale:

      This answer is correct because a blue or dusky appearance to the stoma indicates poor perfusion and inadequate venous return. This can result in a necrotic stoma which requires immediate notification of the surgeon. A beefy red appearance reflects adequate perfusion to the stoma.

  4. Mucus oozing from the stoma.
    • Rationale:

      This answer is not correct because a healthy stoma secretes mucus. The colon and small intestines naturally secretes mucus and is a normal finding.

Overview

Bowel diversion surgery diverts the small or large intestines to an opening in the abdominal wall called a stoma for the purpose of rerouting bodily waste. Blood flow and tissue perfusion is imperative for stoma health. The stoma should be beefy red in appearance to confirm perfusion to the stoma.

Explanation

Learning Outcomes

Bowel diversion surgery diverts the small or large intestines to an opening in the abdomen wall called a stoma for the purpose of rerouting bodily waste. Blood flow and tissue perfusion is imperative for stoma health. A blue or dusky appearance to the stoma indicates poor perfusion and inadequate venous return. This can result in a necrotic stoma which requires immediate notification of the surgeon. The stoma should appear moist and pink or beefy red which shows adequate perfusion. A properly-fitting faceplate protects the skin around the stoma and ensures adequate blood flow to the stoma.

Test Taking Tip

Understand stoma health and how to properly assess a normal and abnormal stoma post bowel diversion surgery.

Video Rationale