Page 1512 - Saunders Comprehensive Review For NCLEX-RN

becomes more solid depending on the
area of creation—ascending colon,
liquid; transverse colon, loose to
semiformed; and descending colon,
close to normal.
h. Monitor the pouch system for proper fit
and signs of leakage; the pouch is
emptied when it is one-third full.
i. Fecal matter should not be allowed to
remain on the skin; skin assessment
and care are a priority.
j. Monitor for dehydration and electrolyte
imbalance.
k. Administer analgesics and antibiotics as
prescribed.
l. Instruct the client to avoid foods that
cause excess gas formation and odor.
m. Instruct the client about stoma care
and irrigations if prescribed (Box 48-
11).
n. Instruct the client that normal activities
may be resumed when approved by
the PHCP.

A stoma that is purple-black in color

indicates compromised circulation, requiring
immediate PHCP notification.
XXVI. Crohn’s Disease
A. Description
1. An inflammatory disease that can occur anywhere in
the gastrointestinal tract but most often affects the
terminal ileum and leads to thickening and scarring, a
narrowed lumen, fistulas, ulcerations, and abscesses
2. Characterized by remissions and exacerbations
B. Assessment
1. Fever
2. Cramp-like and colicky pain after meals

3. Diarrhea (semisolid), which may contain

mucus and pus
4. Abdominal distention
5. Anorexia, nausea, and vomiting
6. Weight loss
7. Anemia

8. Dehydration

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