The nurse should explain to the patient with an ostomy that the blanching and dark red to purple color of the… - NHM UP Staff Nurse - 2019

NHM UP Staff Nurse - 2019

Medical Surgical Nursing

Easy

Appeared in: NHM UP Staff Nurse - 2019

Explanation

A dark red, purple, or blue stoma color is a classic sign of compromised circulation or ischemia, meaning the tissue is not receiving enough oxygenated blood.
This is considered a critical finding and a surgical emergency, as prolonged ischemia can lead to irreversible tissue death (necrosis).
The nurse's priority is to promptly notify the primary care provider or surgeon for immediate intervention.
A healthy, viable stoma should be moist and have a color ranging from dark pink to red, similar to the inside of a healthy mouth.

Option A: This is a description of a normal stoma's composition, not a sign of a complication. A stoma is, by definition, visible intestinal mucosa.
Option B: Anemia causes a pale or light pink appearance to the stoma due to decreased hemoglobin, which is the opposite of the dark red or purple color described.
Option D: The primary signs of a stoma obstruction are related to output (lack of stool/flatus), abdominal cramping, nausea, and distension. While a severe obstruction can eventually cause ischemia, the color change itself is the direct indicator of vascular compromise, not obstruction.

Clinical Relevance

Nursing practice connection: Use the key finding related to Stoma assessment and identification of complications to guide bedside assessment, documentation, and the next nursing action.
Regular and accurate stoma assessment is a critical nursing responsibility in the postoperative period and for ongoing care to detect early signs of complications and ensure patient safety.
Patient education is vital. Patients and their families must be taught how to assess their own stoma color, size, and output, and understand the 'red flag' signs that require immediate medical attention.
What if? If the stoma is protruding significantly more than usual (prolapse) but is still pink and moist, the situation is less emergent than ischemia. The nurse should assess for obstruction, have the patient lie down to reduce pressure, and notify the provider, but it is not the same level of immediate crisis as a purple stoma.

How to Approach the Question

First, identify the key clinical signs presented in the question: a stoma that is 'blanching' and 'dark red to purple'.
Recall the basic physiology of tissue health. All living tissue requires adequate blood supply for oxygen and nutrients. Color is a primary indicator of blood flow.
Analyze the color described. Pink/red indicates good oxygenation. Paleness indicates low blood volume or anemia. Dark red/purple/blue/black indicates a lack of oxygen (ischemia) or tissue death (necrosis).
Evaluate each option based on this physiological understanding. 'Inadequate blood supply' is the only option that directly explains the dark, ischemic coloring.
Differentiate from other options. Anemia causes paleness. Obstruction's primary signs are related to output and abdominal symptoms. Visible mucosa is normal anatomy.

Concept Tested & Keywords

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