The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action?

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11ecbb05_ca7d_4303_b433_197006e50501_MD0009_00 An ileal conduit is a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine. A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a medical emergency (Option D). (Option A) Infection is a potential complication; signs and symptoms of infection may include fever, elevated white blood cell count, odor, and delayed healing. A bluish grey color indicates impaired perfusion, not infection. (Option B) Although the nurse will document the findings and monitor for changes, lack of perfusion to the stoma is an emergency that must be reported immediately. (Option C) Applying an appropriate-size pouching system (approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma and reduces the risk for infection. These are important concepts of stoma care but are not the priority at this time. Educational objective: Stoma care involves frequent nursing assessment for signs of potential complications such as impaired perfusion, infection, and wound dehiscence. The stoma should be pink to brick-red and moist. Suspected impaired perfusion is considered a surgical emergency and should be reported immediately.

The Nurse Is Caring for a Client with an Ileal