Question

The nurse is caring for a client who is 24 hours post procedure for a hemicolectomy with a temporary colostomy placement. The nurses assess the client's stoma, which is dry and dark blue. Which action should the nurse take based on this finding?

A. Notify the healthcare provider of the finding
B. Document the finding in the client record.
C. Replace the pouch system over the stoma.
D. Place petrolatum gauze dressing on the stoma.

Answer 1

The nurse should assess the vascularity of the stoma, notify the healthcare team, and document the findings.

Step-by-step explanation:

Based on the finding of a dry and dark blue stoma, the nurse should take the following action:

• Assess the vascularity of the stoma: A dark blue color indicates decreased blood supply to the stoma, which can be a sign of ischemia or necrosis. The nurse should check for any signs of bleeding, edema, or necrotic tissue around the stoma.
• Notify the healthcare team: The nurse should promptly report the finding to the healthcare team, as a decrease in blood supply to the stoma requires immediate intervention to prevent further complications.
• Document the findings: The nurse should accurately document the assessment findings, including the color, appearance, and any other abnormalities observed in the stoma. This documentation will provide a baseline for comparison and help track the client's progress.