A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

Choice A rationale

A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.

Choice B rationale

A rosebud-like stoma orifice is a normal finding and does not need to be reported18.

Choice C rationale

A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.

Choice D rationale

A shiny, moist stoma is a normal finding and does not need to be reported18.

Choice A rationale: Wet-to-dry dressings are a form of mechanical debridement. This method involves applying a wet dressing to the wound and allowing it to dry. When the dressing is removed, it also removes some of the dead or damaged tissue from the wound, helping to clean the wound and promote healing. This method can be painful and is not selective, meaning it can also remove healthy tissue. However, it is often used for wounds with a large amount of debris or necrotic tissue.

Choice B rationale: Surgical debridement is another method of wound debridement, but it is not a form of mechanical debridement. This method involves using surgical instruments to remove dead or damaged tissue. It is the fastest method of debridement and is often used for wounds that are infected or have a large amount of necrotic tissue. However, it requires a skilled practitioner and can be painful.

Choice C rationale: Enzymatic debridement involves applying a topical ointment that contains enzymes to the wound. These enzymes help to break down dead or damaged tissue. This method is selective and only removes necrotic tissue, leaving healthy tissue intact. However, it is not a form of mechanical debridement.

Choice D rationale: Autolytic debridement is a method that uses the body’s own enzymes and moisture to break down dead or damaged tissue. This is the slowest method of debridement but is also the least painful and is selective for necrotic tissue. Like enzymatic debridement, autolytic debridement is not a form of mechanical debridement.