# Situation: A 58-year-old man had a sigmoid resection with an end colostomy in the left lower quadrant (Hartmann procedure) for perforated diverticulitis. On the third postoperative day, the nurse compares the stoma with day 1. Day 1: red, moist, swollen, protruding 1.5 cm above the skin; stoma–skin junction intact Day 3: red and moist, now level with the skin on one side and about 0.5 cm below it on the other; stoma–skin junction intact; no stool yet How should the nurse classify the day 3 change?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630487  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 58-year-old man had a sigmoid resection with an end colostomy in the left lower quadrant (Hartmann procedure) for perforated diverticulitis.

On the third postoperative day, the nurse compares the stoma with day 1.
Day 1: red, moist, swollen, protruding 1.5 cm above the skin; stoma–skin junction intact
Day 3: red and moist, now level with the skin on one side and about 0.5 cm below it on the other; stoma–skin junction intact; no stool yet
How should the nurse classify the day 3 change?

## 보기

1. Early stoma prolapse that needs to be reported
2. Mucocutaneous separation that needs to be reported
3. Stoma retraction that needs to be reported **✔ 정답**
4. Expected shrinking as the early swelling settles

**정답: 3**

## 해설

Mild edema and protrusion are expected early, and edema settles over weeks, but a stoma that sinks below the level of the skin is retracting. Retraction causes leakage and skin damage and is reported. The intact junction rules out mucocutaneous separation, and no stool by day 3 is still within the expected 2–5 days.

## 심화 해설

Recognizing stoma retraction
A healthy new colostomy is red and moist, often swollen, and usually protrudes slightly above the skin. On day 1 his stoma protruded 1.5 cm. By day 3 it is level with the skin on one side and about 0.5 cm below it on the other, while the stoma–skin (mucocutaneous) junction remains intact. A stoma that is drawn below skin level is retracting. Settling edema may make a stoma smaller, but it should not pull the stoma below the level of the skin. The change is reported to the surgeon.

Why retraction matters
Retraction is often caused by tension on the bowel, obesity, or early postoperative swelling pulling the stoma inward. A retracted stoma makes it difficult to achieve a secure pouch seal, so stool leaks under the barrier and damages the surrounding skin. Early recognition allows the surgeon and stoma care nurse to assess the cause and adjust management, for example with a convex appliance, and to watch for progression.

| Complication | Key finding | His stoma |
| --- | --- | --- |
| Retraction | Stoma sinks to or below skin level | Present |
| Prolapse | Stoma lengthens outward | Absent |
| Mucocutaneous separation | Break at the stoma–skin junction | Junction intact |
| Expected edema settling | Less swelling, still above skin | Not this; below skin on one side |

Why the other options are wrong
Prolapse is the opposite change: the stoma telescopes outward and becomes longer. Mucocutaneous separation is a gap between the stoma and the surrounding skin, but his junction is intact. Calling the change expected shrinking confuses normal reduction of swelling, which occurs over weeks, with a stoma dropping below the skin. The absence of stool by day 3 is not part of the problem; colostomy output commonly begins within about 2–5 days. Watch out! The word "below" the skin is the key finding that separates retraction from normal settling.

Exam takeaway
Assess a new stoma for color, moisture, size, height relative to the skin, the integrity of the junction, and output. A dusky or black stoma suggests ischemia and is reported urgently. Key point! A stoma that sinks below skin level is retraction and is reported, even when the stoma looks healthy and the junction is intact.

## 임상 시나리오

Postoperative Stoma AssessmentRetraction versus expected changes
A new colostomy is red, moist, and swollen. Edema settles over weeks, but the stoma should stay above the skin.

A stoma that is level with or 0.5 cm below the skin is retracting; it causes leakage and skin damage and is reported.

An intact stoma–skin junction rules out mucocutaneous separation. No stool by day 3 is still within the expected 2–5 days.

CautionA dusky, purple, or black stoma signals ischemia and needs urgent reporting.

## 핵심 개념

- **Stoma retraction** — Sinking of the stoma to or below the level of the skin, which causes pouch leakage and skin damage.
- **Stoma prolapse** — Outward telescoping of the bowel through the stoma, making it longer than expected.
- **Mucocutaneous separation** — Separation of the stoma from the surrounding skin at the suture line.
- **Hartmann procedure** — Resection of the sigmoid colon with an end colostomy and closure of the rectal stump.

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