A nurse is caring for a 45-year-old light-skinned male client who has an ileostomy in an inpatient setting.

Exhibits

A nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding.

Nurses Notes: Day 1: The client's abdomen is soft and nondistended, with the presence of an ileostomy. The stoma is red and is draining brown liquid stool. The client refuses to look at the stoma and expresses no interest in learning about stoma care.

Day 2: The ileostomy pouch was changed. The skin surrounding the stoma is reddened and has small open areas. The client continues to refuse to look at the stoma and is not interested in learning about its care. During cleaning, a small amount of bleeding was noted from the stoma.

Physical Examination Results: The client appears alert and oriented to person, place, and time. His abdomen is soft and nondistended with an ileostomy present. The stoma is red and draining brown liquid stool. The skin surrounding the stoma is reddened with small open areas. During cleaning, a small amount of bleeding was noted from the stoma.

Findings that require follow-up:

1. Refuses to look at the stoma:
   • This indicates the client is experiencing emotional or psychological distress related to the ileostomy. It may hinder his ability to learn and participate in self-care, which is crucial for managing the ileostomy effectively.
2. Expresses no interest in learning about stoma care:
   • Lack of interest in learning about stoma care suggests the client is not prepared or willing to take responsibility for his own care, which can lead to complications and poor outcomes. Education and support are needed to help the client become more comfortable and knowledgeable about managing the ileostomy.
3. The skin surrounding the stoma is reddened and has small open areas:
   • This indicates irritation or infection of the skin around the stoma, which requires prompt attention to prevent further complications and ensure proper healing. It may be necessary to review the client's stoma care routine and make adjustments to prevent skin breakdown.
4. During cleaning, a small amount of bleeding was noted from the stoma:
   • Bleeding from the stoma can be a sign of trauma, infection, or other issues that need to be addressed. Prompt evaluation and intervention are necessary to identify the cause and prevent further complications.

Findings that do not require follow-up:

1. The client's abdomen is soft and nondistended:
   • This is a normal finding, indicating that there is no abdominal distention or rigidity, which could be signs of underlying issues such as bowel obstruction or peritonitis.
2. The stoma is red and is draining brown liquid stool:
   • A red stoma with brown liquid stool is generally a normal finding, as the stoma should be red or pink in color and the stool consistency can vary based on the type of ileostomy and the client's diet.
3. The client appears alert and oriented to person, place, and time:
   • This indicates the client is mentally alert and aware of his surroundings, which is a positive sign of overall cognitive function and well-being.
4. The ileostomy pouch was changed:
   • Changing the ileostomy pouch is a routine part of stoma care and does not indicate any issues that require follow-up unless there are problems noted during the process, such as skin irritation or pouch leakage.