A nurse is assessing a client who is 8 hours post-op followi… | MyMerci
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Basic Care and Comfort

A nurse is assessing a client who is 8 hours post-op following an ileostomy creation. Which finding requires immediate follow-up?

Chart/Exhibit

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History
Vitals
Labs
Orders
Notes
Client underwent ileostomy creation 8 hours ago for ulcerative colitis. No known allergies. Past medical history unremarkable.
BP 118/72, HR 88, RR 16, Temp 98.8°F (37.1°C), SpO2 98% on room air
Hgb 11.2 g/dL, WBC 9,500/mm³
Vital signs every 4 hours, stoma assessment every 4 hours, advance diet as tolerated, pain management per protocol
Client is drowsy but arousable. Abdomen soft, bowel sounds hypoactive. Stoma appears dusky and purplish with dry surface. No frank bleeding. Dressing has small amount of serosanguineous drainage.
Explanation
A viable new stoma should be moist and red to pink. A dusky, purplish, or dry stoma suggests impaired blood flow and possible ischemia, which requires immediate evaluation. A moist, red stoma with slight edema is a normal postoperative finding. A small amount of serosanguineous drainage is expected in the early postoperative period. Mild incisional pain rated 3/10 is common after surgery and does not indicate an emergency.
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