# Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions. On the first postoperative day, the nurse assesses the stoma. It is beefy red, moist, and swollen about 1 cm above the skin, and it has passed no stool or flatus yet. His abdomen is soft, he has no nausea, and the peristomal skin is intact. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629735  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions.

On the first postoperative day, the nurse assesses the stoma. It is beefy red, moist, and swollen about 1 cm above the skin, and it has passed no stool or flatus yet. His abdomen is soft, he has no nausea, and the peristomal skin is intact. Which action should the nurse take?

## 보기

1. Report the swelling as a sign of stoma obstruction
2. Insert a gloved finger to check that the stoma is patent
3. Notify the surgeon that the colostomy has not yet functioned
4. Record the findings and continue routine stoma checks **✔ 정답**

**정답: 4**

## 해설

A healthy new stoma is beefy red or pink and moist, and mild edema is expected in the first days. A colostomy usually begins to function in about 2 to 5 days, so no output on day 1 with a soft abdomen and no nausea is expected. The nurse documents and continues monitoring; a pale, dusky, purple, or black stoma, or distension with vomiting, would be reported.

## 심화 해설

Expected postoperative stoma appearance
On the first day after abdominoperineal resection with permanent sigmoid colostomy, a stoma that is beefy red, moist, and mildly edematous is a normal finding. The mucosa of the exteriorized bowel remains well perfused, giving it the characteristic red-pink color. Postoperative edema typically peaks within the first 48–72 hours and then gradually subsides. A protrusion of about 1 cm above the skin is consistent with expected swelling rather than prolapse or obstruction. Mild stomal edema alone, in the absence of abdominal distension, nausea, or vomiting, does not indicate obstruction.

Expected timing of colostomy function
A sigmoid colostomy generally begins to pass stool or flatus between 2 and 5 days after surgery. On postoperative day 1, the absence of output is anticipated because bowel peristalsis has not yet fully resumed following anesthesia and bowel manipulation. The patient's soft abdomen and lack of nausea are reassuring signs that there is no ileus or mechanical blockage. No stool or flatus on day 1, with a soft abdomen and no nausea, is an expected finding that does not require surgeon notification.

Why the other actions are incorrect
Watch out! Digital examination of a fresh stoma is contraindicated in the early postoperative period. Inserting a gloved finger can disrupt the mucocutaneous suture line, cause trauma to the edematous mucosa, or introduce infection. Stoma patency is assessed through clinical signs such as flatus passage, stool output, and absence of obstructive symptoms, not by routine digital insertion. Reporting the swelling as obstruction is also incorrect because edema is a normal inflammatory response to surgical manipulation. Notifying the surgeon that the colostomy has not functioned is premature on day 1, as function typically begins later.

Findings that would require reporting
The nurse should monitor for signs of stoma ischemia or necrosis, which present as a stoma that becomes pale, dusky, purple, or black. These color changes indicate compromised blood supply to the exteriorized bowel segment and require immediate surgical evaluation. Key point! A healthy stoma is always moist and red-pink; any darkening or drying suggests vascular compromise. Additionally, progressive abdominal distension with vomiting, or failure to pass flatus or stool beyond 5 days, would warrant reporting for possible obstruction or ileus.

Clinical reasoning for the correct action
The nurse should document the assessment findings and continue routine stoma monitoring. This includes checking the stoma color, moisture, edema, and peristomal skin integrity at regular intervals, as well as monitoring for the first passage of flatus and stool. A beefy red, moist, mildly edematous stoma with intact peristomal skin on postoperative day 1 represents a healthy, well-perfused stoma in the early healing phase. The soft abdomen and absence of nausea further support that bowel function is recovering normally. No intervention beyond ongoing observation is required at this time.

## 임상 시나리오

Postoperative Stoma AssessmentDay 1 normal findings and monitoring priorities
A healthy new stoma is beefy red or pink and moist. Mild edema peaking within 48–72 hours is expected, and protrusion of about 1 cm above the skin is consistent with normal swelling rather than prolapse or obstruction.

A sigmoid colostomy typically begins to function in 2–5 days. No stool or flatus on day 1 with a soft abdomen and no nausea is an expected finding that does not require surgeon notification.

CautionReport a pale, dusky, purple, or black stoma immediately as a sign of ischemia. Also report abdominal distension with vomiting, which may indicate obstruction or ileus. Never insert a gloved finger into a fresh stoma; this can disrupt the mucocutaneous suture line and cause trauma or infection.

## 핵심 개념

- **Abdominoperineal resection** — Surgical removal of the rectum and anus with creation of a permanent colostomy, commonly for low rectal cancer.
- **Stoma edema** — Expected postoperative swelling of the exteriorized bowel mucosa that peaks within 48–72 hours and gradually subsides.
- **Mucocutaneous suture line** — The junction where the bowel mucosa is sutured to the skin; vulnerable to disruption from digital manipulation in the early postoperative period.
- **Sigmoid colostomy** — A stoma created from the sigmoid colon that typically begins passing stool or flatus 2–5 days after surgery.
- **Stoma ischemia** — Compromised blood flow to the stoma presenting as a pale, dusky, purple, or black appearance; requires immediate reporting.

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