The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

The correct answer is Choice A.

Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.

Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.

Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.

Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.

The correct answer is Choice B.

Choice A rationale: Waiting until the ostomy drainage bag is full increases the risk of leakage and can put undue pressure on the stoma, leading to potential skin irritation or damage. Regular emptying is crucial for maintaining stoma health and preventing complications.

Choice B rationale: Emptying the ostomy drainage bag when it is 1/2 full is recommended to prevent leaks and reduce pressure on the stoma. This practice helps maintain skin integrity around the stoma and ensures the drainage bag functions effectively.

Choice C rationale: Emptying the ostomy drainage bag when it is only 1/4 full may be too frequent and unnecessary, leading to increased use of supplies and potential irritation from frequent manipulation. It is more practical to aim for 1/2 full for routine care.

Choice D rationale: Waiting until the ostomy drainage bag is 3/4 full increases the risk of leakage and pressure on the stoma, similar to waiting until it is full. It is essential to empty the bag more regularly to maintain optimal stoma health and prevent issues