# A nurse is caring for a client with Crohn's disease who underwent a small bowel resection with temporary ileostomy 3 days ago. The client reports severe cramping pain and the nurse observes that the stoma is dark red and dusky. What is the most appropriate immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540730 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with Crohn's disease who underwent a small bowel resection with temporary ileostomy 3 days ago. The client reports severe cramping pain and the nurse observes that the stoma is dark red and dusky. What is the most appropriate immediate nursing intervention? ## 보기 1. Apply a warm compress to the stoma site 2. Irrigate the colostomy with normal saline 3. Notify the surgeon immediately **✔ 정답** 4. Administer prescribed pain medication **정답: 3** ## 해설 A dark red, dusky stoma indicates ischemia or necrosis, a surgical emergency requiring immediate surgeon notification. Other interventions (warm compress, irrigation, pain meds) delay critical care and may worsen the condition. ## 심화 해설 Understanding the Clinical Scenario The client is 3 days post-operative from a small bowel resection with a temporary ileostomy. The sudden onset of severe cramping pain combined with a stoma that appears dark red and dusky is a critical change. A healthy, viable stoma should be moist, rose pink to beefy red, and edematous in the initial post-operative period. The color change to a dusky, dark red indicates a disruption in blood supply. Analyzing the Pathophysiology The appearance of a dark red or dusky stoma is a classic sign of stomal ischemia. Ischemia means that the blood flow to the stoma is compromised. This can occur due to venous congestion or arterial insufficiency. If the blood supply is not quickly restored, the tissue will become necrotic, turning black and dry. This is a serious, time-sensitive complication. As noted in the literature, serious complications from stoma creation can occur that require immediate reoperation [1]. Ischemia is specifically listed as a common and significant complication [1]. The severe cramping pain the client is experiencing is likely a direct result of this ischemic process, as the bowel tissue is deprived of oxygen. Evaluating the Options - Option 1: Apply a warm compress to the stoma site. This action is inappropriate and potentially harmful. Applying warmth to an ischemic stoma could increase the tissue's metabolic demand for oxygen, which the compromised blood supply cannot meet, thereby accelerating tissue necrosis. It does not address the underlying circulatory problem. - Option 2: Irrigate the colostomy with normal saline. This intervention is incorrect on two counts. First, the client has an ileostomy, not a colostomy, and irrigation is not a standard practice for ileostomies due to the liquid nature of the effluent. Second, and more critically, irrigating a stoma with a compromised blood supply could cause further trauma and perforation of the fragile tissue. - Option 3: Notify the surgeon immediately. This is the most appropriate and urgent action. The assessment findings of a dusky stoma and severe pain are indicative of a surgical emergency. The surgeon must be notified at once to evaluate the stoma, as prompt intervention is the only way to potentially salvage the ischemic bowel. Delaying this notification could lead to irreversible necrosis, requiring a more extensive surgical revision. - Option 4: Administer prescribed pain medication. While addressing the client's pain is important, this is not the priority action. Administering an analgesic would mask a critical symptom of a developing surgical emergency without addressing the underlying cause. The nurse must first recognize the significance of the assessment findings and obtain immediate medical intervention. The Priority Nursing Intervention The nurse's immediate priority is to recognize that the dusky stoma and severe pain are signs of a potentially life-threatening complication. The standard of care for a patient with an intestinal stoma involves vigilant post-operative assessment to prevent and identify complications early . The nurse's role is crucial in detecting changes like ischemia, which is a known complication following ileostomy creation . The correct action is to escalate this finding to the surgeon without delay. The administration of pain medication, while a comfort measure, is secondary to the need for an immediate surgical evaluation to preserve tissue viability.References (research sources) - [1]Avoidance and management of stomal complications.Research articleKwiatt M, Kawata M. (2013) · DOI: 10.1055/s-0033-1348050 ## 임상 시나리오 Stoma Assessment & Ischemia ManagementRecognizing and Responding to a Vascular Emergency A viable stoma is moist and rose pink to beefy red. A dusky, dark red, or blue-tinged stoma indicates ischemia from compromised blood flow, which can progress to necrosis (black, dry tissue) if not promptly reversed. The immediate priority for suspected stomal ischemia is to notify the surgeon immediately. This is a time-sensitive, life-threatening complication often requiring urgent reoperation to restore blood supply before irreversible tissue death occurs. CautionNever apply heat to an ischemic stoma; it increases metabolic oxygen demand and accelerates necrosis. Do not delay intervention by irrigating an ileostomy or administering analgesics, which mask the critical symptom of pain. ## 핵심 개념 - **Stomal Ischemia** — Compromised blood flow to the stoma tissue, presenting as a dusky or dark red color, often due to venous congestion or arterial insufficiency, and a precursor to necrosis. - **Ileostomy** — A surgical opening created in the ileum (small intestine) to divert fecal matter, typically producing liquid to pasty effluent. - **Necrosis** — Tissue death caused by prolonged ischemia, characterized by a black, dry, and non-viable stoma. ## 같은 주제 문제 - [A nurse is assessing a 58-year-old client who was recently diagnosed with colorectal cance…](https://mymerci.kr/pages/nclex_q.php?qn_id=540726) - [A nurse is assessing a 58-year-old client who has been diagnosed with colorectal cancer. 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