A nurse is managing the care of a female client with an ileostomy who has been experiencing complications and has recently undergone a stoma revision. The client’s condition is evolving over several days, and the nurse is reviewing all relevant exhibits to assess the need for further intervention.

Exhibits

Based on the exhibits provided, which findings require immediate intervention by the nurse? Select all that apply.

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

Choice A rationale: The stoma has a bluish discoloration and is bleeding extensively. This is a significant finding that requires immediate intervention. A bluish or dusky color indicates poor blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Extensive bleeding is also a concerning symptom that could indicate damage to the stoma or surrounding tissue. It’s important for the nurse to assess the stoma and notify the healthcare provider immediately to prevent further complications.

Choice B rationale: The skin surrounding the stoma has large open sores with oozing. This is another critical finding that needs immediate attention. Open sores and oozing can indicate a severe skin breakdown or infection, which can lead to further complications if not treated promptly. The nurse should clean the area, apply appropriate dressings, and consult with the wound care team or healthcare provider for further management.

Choice C rationale: The client is exhibiting a temperature of 37.8°C (100.0°F). While this temperature is not extremely high, it is slightly elevated and could be an early sign of infection, especially when considered in the context of the other symptoms the client is experiencing. The nurse should continue to monitor the client’s temperature and other vital signs, and report any significant changes to the healthcare provider.

Choice E rationale: The client reports increased nausea and vomiting. These symptoms can lead to dehydration and electrolyte imbalances, which can further complicate the client’s condition. The nurse should assess the client’s hydration status, provide interventions to manage nausea and vomiting, and monitor the client’s electrolyte levels.

Choice G rationale: The client refuses to participate in stoma care education. While this may not seem like an immediate medical concern, it is a significant issue that requires intervention. The client’s refusal to learn about stoma care can hinder their recovery and long-term management of the ileostomy. The nurse should explore the reasons behind the client’s refusal, provide emotional support, and use different strategies to encourage the client’s participation in stoma care education.