Page 1287 - Saunders Comprehensive Review For NCLEX-RN

and signs of leakage; empty the pouch
when one-third full.
c. Monitor the stoma for size, unusual
bleeding, color changes, or necrotic
tissue.
d. Note that the normal stoma color is red
or pink, indicating high vascularity.
e. Note that a pale pink stoma indicates
low hemoglobin and hematocrit levels.
f. Assess the functioning of the colostomy.
g. Expect that stool will be liquid
postoperatively but will become more
solid, depending on the area of the
colostomy.
h. Expect liquid stool from an ascending
colon colostomy, loose to semiformed
stool from a transverse colon
colostomy, or close to normal stool
from a descending colon colostomy.
i. Fecal matter should not be allowed to
remain on the skin.
j. Administer analgesics and antibiotics as
prescribed.
k. Irrigate perineal wound if present and
if prescribed, and monitor for signs of
infection; provide comfort measures
for perineal itching and pain.
l. Instruct the client to avoid foods that
cause excessive gas formation and
odor.
m. Instruct the client in stoma care and
irrigations as prescribed.
n. Instruct the client on when to resume
normal activities, including work,
travel, and sexual intercourse, as
prescribed; provide psychosocial
support.
3. Postoperative: Ileostomy
a. Healthy stoma is red in color.
b. Postoperative drainage will be dark
green and progress to yellow as the
client begins to eat.
c. Stool is liquid.

d. Risk for dehydration and

electrolyte imbalance exists.

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