護理師照護一位新造口病人,下列哪些發現需通知醫療團隊?(選所有適合的)
A nurse is caring for a client with a new colostomy. Which findings should the nurse report to the healthcare provider? (Select all that apply.)
- AStoma appears dark purple or black✓ 正解造口呈現暗紫色或黑色
- BStoma is red and moist造口呈紅色且濕潤
- CModerate amount of mucus drainage from the stoma造口有中等量的黏液排出
- DStoma bleeds easily when wiped gently輕輕擦拭時造口容易出血
- ENo stool output 48 hours post-operatively✓ 正解術後 48 小時無糞便排出
造口(Stoma)術後評估重點在於血液循環與腸道蠕動恢復。正常的造口應呈鮮紅色且濕潤,若出現深紫色或黑色,顯示組織缺血壞死(Ischemia),為需立即處理的急症。此外,術後腸道麻痺(Paralytic ileus)常導致術後 24-48 小時內無糞便排出,但若超過 48 小時仍無產出,需懷疑機械性阻塞或腸道功能異常,必須通知醫療團隊進行評估。
Postoperative stoma assessment focuses on blood supply and return of bowel function. A normal stoma should appear bright red and moist; if it appears dark purple or black, this indicates ischemia and tissue necrosis, an emergency requiring immediate intervention. Additionally, postoperative paralytic ileus often results in no stool output within the first 24-48 hours, but if more than 48 hours pass with no output, mechanical obstruction or impaired bowel function must be suspected and the provider must be notified for evaluation.