Question

The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment?

1.Apply ice to the stoma site.
2.Apply pressure to the stoma site.
3.Notify the health care provider (HCP).
4.Document the amount and characteristics of the drainage.

Answer 1

The nurse should document the amount and characteristics of the serosanguineous drainage which is expected postoperatively from a new colostomy. Other actions such as applying ice or pressure, or notifying the healthcare provider are not immediately necessary unless other complications arise.

Step-by-step explanation:

The nurse caring for a client who has a new colostomy and notes serosanguineous drainage should understand that this type of drainage is typically expected in the early postoperative period as it is a combination of serum and blood. The most appropriate nursing action in this scenario is to document the amount and characteristics of the drainage. Applying ice or pressure is not appropriate for serosanguineous drainage without further indication, and while it is important to be vigilant for signs of complications, notifying the healthcare provider is not necessary unless there are additional concerns such as excessive bleeding, signs of infection, or a marked change in the stoma's appearance or output. The nurse should continue to monitor the drainage and assess the client's overall condition, intervening as appropriate.