Question

0800:

Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants.

1200:
Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool.

Diagnostic Results

1200:
Hgb 19 g/dL (12 to 16 g/dL)
Hct 46% (37% to 47%)

Complete the following sentence by using the lists of options.

Part 1: The nurse should first address the ___________

a. Stoma color
b. Hemoglobin level
c. Ostomy leakage
Part 2: followed by the ______________

a. Ostomy pouch seal
b. Skin around the stoma
c. Amount of stool in the pouch

Answer 1

The nurse should first address the stoma color, followed by the ostomy pouch seal.

Step-by-step explanation:

Part 1: The nurse should first address the stoma color because it appears dark purple with blistering on the skin around the stoma, which may indicate ischemia or necrosis. This is a concerning finding that requires immediate attention.

Part 2: The nurse should then address the ostomy pouch seal because it is slightly leaking, leading to the stool leakage. A secure pouch seal is important to prevent skin irritation and infection.