Fundamentals of Nursing Q 425
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
A. The stoma extends 1/2 inch above the abdomen.
B. The skin under the appliance looks red briefly after removing the appliance.
C. The stoma color is a deep red purple.
D. An ascending colostomy just delivers liquid feces.
Correct Answer: C. The stoma color is a deep red purple.
An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel. It may be temporary or permanent, depending on the indication for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma.
Option A: The stoma should be assessed and must be moist, above skin level, and pink to red in color, and the peristomal skin should be normal. Any deviation from this should be notified to the surgeon. The stoma should be measured, or the previous measurement remembered and size should not be more than 1/16-1/8.
Option B: The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. The peristomal skin should be dried appropriately to allow good seal formation. Adhesive pastes or powders may also be applied peristomally. The paper cover on the back of the flange is then removed with the border tape in place. It is then placed around the stoma and held in place for 1 to 2 minutes to create an adequate seal.
Option D: Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma. Colostomy diarrhea may be complained by the patient in case of ascending or transverse colostomies in case they are not fully explained about the nature of content expected, but stomal diarrhea may be the result of extensive resection with failure of bowel adaptation or if associated with short bowel syndrome.