The nurse is continuing to care for the client. 

Exhibits

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Rationale:

A. I should clean my stoma with moisturizing soap: Moisturizing soaps can leave a residue that interferes with the adhesive of the pouching system. The stoma area should be cleaned with warm water or a mild, non-moisturizing soap to ensure the pouch adheres properly.

B. I should cut my pouch opening 1/8 inch larger than my stoma: The opening should be just slightly larger than the stoma about 1/8 inch to prevent constriction while still protecting the surrounding skin from effluent and minimizing skin irritation.

C. I should expect my stoma to be blistered: A healthy stoma should appear moist, pink or red, and smooth. Blistering is a sign of skin breakdown or irritation and indicates improper pouch fitting or leakage, which requires intervention.

D. I should change my stoma pouch 30 minutes after heals: There isn't a specific 30-minute post-meal rule. The most important guideline for changing a pouch is when it's about one-third to one-half full, or if there is leakage or discomfort.

Rationale:

A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.

B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.

C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.

D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.