Summary Patient Care Rounds: Bowel
Diversion (Miguel Flores) 2025
Comprehensive Post-Operative Care
Assessment
Patient Context: Miguel Flores, 68-year-old male, post-operative day 2 status post sigmoid
colectomy with end colostomy creation for complicated diverticulitis with perforation. Past
medical history includes hypertension and type 2 diabetes. Current medications include
metoprolol, metformin (held), and patient-controlled analgesia (PCA) with hydromorphone.
He is NPO with IV fluids, Foley catheter to gravity drainage, and Jackson-Pratt (JP) drain to
bulb suction. He lives with his wife, Maria, who is his primary caregiver. The interdisciplinary
team (Surgeon, Enterostomal Therapy Nurse [ETN], Registered Dietitian, Social Worker, and
Bedside RN) is conducting patient care rounds.
Current Assessment Data:
● Vitals: T 99.1°F (37.3°C), HR 88 bpm, BP 132/78 mmHg, RR 16, SpO2 96% on room air
● Pain: 4/10 at incision site, controlled with PCA
● Stoma: Located in the descending colostomy position (left lower quadrant), beefy red, moist,
slightly edematous (2+), 2.5 cm above skin level, no bleeding
● Output: 200 mL serosanguinous liquid stool in past 8 hours
● Peristomal skin: Intact, no erythema or breakdown
● Abdomen: Soft, non-distended, hypoactive bowel sounds in all quadrants
● I&O: Intake 1800 mL, Output 1400 mL (urine 1200 mL, JP 150 mL, stoma 50 mL)
● Labs: WBC 11.2 (↓ from 14.8 post-op day 0), Hgb 10.8 g/dL, K+ 3.6 mEq/L, Creatinine 1.1
mg/dL
Section 1: Immediate Post-Op Assessment (Q1-3)
Q1: The surgical resident asks the bedside nurse, "How do we know this stoma is viable and
well-perfused?" The nurse responds by identifying which characteristic as the PRIMARY
indicator of adequate blood supply?
A. The stoma protrudes 2.5 cm above the abdominal wall surface
B. The stoma is beefy red, moist, and blanches to touch with prompt return of color
[CORRECT]
, C. The stoma produces liquid serosanguinous output every 2-3 hours
D. The stoma is located in the left lower quadrant at the pre-marked site
Correct Answer: B
Rationale: Stoma viability is assessed primarily by color and capillary refill, which indicate
arterial perfusion and venous return. A healthy stoma should be beefy red to pink, moist, and
blanch when touched with return of color within 2 seconds. This reflects adequate blood
supply from the mesenteric vessels. Dark purple, black, or dusky stomas indicate ischemia or
necrosis requiring immediate surgical consultation. While stomal protrusion (A) is important
for pouching (ideally 1-2 cm above skin to allow effluent to flow into pouch), it does not
indicate perfusion. Output (C) indicates function but not vascular status. Location (D) is
determined pre-operatively by the ETN for optimal patient visibility and self-care, but does not
indicate perfusion. Reference: WOCN Society Guidelines for Management of the Adult Patient
with a Fecal or Urinary Ostomy (2024).
Q2: During the physical assessment, the nurse notes the stoma appears slightly dusky at the
distal tip and the patient reports increased incisional pain. The JP drain output has decreased
from 100 mL to 20 mL over 8 hours, and the bulb appears fully expanded. What is the nurse's
PRIORITY action?
A. Document the findings and continue routine monitoring every 4 hours
B. Milk the JP drain tubing to restore patency and notify the surgeon [CORRECT]
C. Apply a warm compress to the stoma to improve blood flow
D. Increase the PCA dose to address the patient's pain complaint
Correct Answer: B
Rationale: The combination of decreased JP output despite fluid accumulation (expanded
bulb), increased pain, and subtle stoma color change suggests possible internal fluid
collection/hematoma causing compression on the stoma's blood supply or the surgical
anastomosis. The priority is to ensure drain patency (milking/stripping the tubing) to relieve
pressure and immediately notify the surgeon, as this may indicate a developing complication
requiring intervention. Option A delays necessary intervention. Option C is
inappropriate—warm compresses do not address vascular compromise from external
compression and may mask deterioration. Option D treats the symptom (pain) without
investigating the cause, which could be anastomotic leak or ischemia. This requires
interdisciplinary communication with the surgical team stat.
Q3: The nurse is reviewing the PCA usage and pain assessment. Mr. Flores has used 8 mg of
hydromorphone in the past 24 hours via PCA with a 0.2 mg demand dose and 10-minute
Diversion (Miguel Flores) 2025
Comprehensive Post-Operative Care
Assessment
Patient Context: Miguel Flores, 68-year-old male, post-operative day 2 status post sigmoid
colectomy with end colostomy creation for complicated diverticulitis with perforation. Past
medical history includes hypertension and type 2 diabetes. Current medications include
metoprolol, metformin (held), and patient-controlled analgesia (PCA) with hydromorphone.
He is NPO with IV fluids, Foley catheter to gravity drainage, and Jackson-Pratt (JP) drain to
bulb suction. He lives with his wife, Maria, who is his primary caregiver. The interdisciplinary
team (Surgeon, Enterostomal Therapy Nurse [ETN], Registered Dietitian, Social Worker, and
Bedside RN) is conducting patient care rounds.
Current Assessment Data:
● Vitals: T 99.1°F (37.3°C), HR 88 bpm, BP 132/78 mmHg, RR 16, SpO2 96% on room air
● Pain: 4/10 at incision site, controlled with PCA
● Stoma: Located in the descending colostomy position (left lower quadrant), beefy red, moist,
slightly edematous (2+), 2.5 cm above skin level, no bleeding
● Output: 200 mL serosanguinous liquid stool in past 8 hours
● Peristomal skin: Intact, no erythema or breakdown
● Abdomen: Soft, non-distended, hypoactive bowel sounds in all quadrants
● I&O: Intake 1800 mL, Output 1400 mL (urine 1200 mL, JP 150 mL, stoma 50 mL)
● Labs: WBC 11.2 (↓ from 14.8 post-op day 0), Hgb 10.8 g/dL, K+ 3.6 mEq/L, Creatinine 1.1
mg/dL
Section 1: Immediate Post-Op Assessment (Q1-3)
Q1: The surgical resident asks the bedside nurse, "How do we know this stoma is viable and
well-perfused?" The nurse responds by identifying which characteristic as the PRIMARY
indicator of adequate blood supply?
A. The stoma protrudes 2.5 cm above the abdominal wall surface
B. The stoma is beefy red, moist, and blanches to touch with prompt return of color
[CORRECT]
, C. The stoma produces liquid serosanguinous output every 2-3 hours
D. The stoma is located in the left lower quadrant at the pre-marked site
Correct Answer: B
Rationale: Stoma viability is assessed primarily by color and capillary refill, which indicate
arterial perfusion and venous return. A healthy stoma should be beefy red to pink, moist, and
blanch when touched with return of color within 2 seconds. This reflects adequate blood
supply from the mesenteric vessels. Dark purple, black, or dusky stomas indicate ischemia or
necrosis requiring immediate surgical consultation. While stomal protrusion (A) is important
for pouching (ideally 1-2 cm above skin to allow effluent to flow into pouch), it does not
indicate perfusion. Output (C) indicates function but not vascular status. Location (D) is
determined pre-operatively by the ETN for optimal patient visibility and self-care, but does not
indicate perfusion. Reference: WOCN Society Guidelines for Management of the Adult Patient
with a Fecal or Urinary Ostomy (2024).
Q2: During the physical assessment, the nurse notes the stoma appears slightly dusky at the
distal tip and the patient reports increased incisional pain. The JP drain output has decreased
from 100 mL to 20 mL over 8 hours, and the bulb appears fully expanded. What is the nurse's
PRIORITY action?
A. Document the findings and continue routine monitoring every 4 hours
B. Milk the JP drain tubing to restore patency and notify the surgeon [CORRECT]
C. Apply a warm compress to the stoma to improve blood flow
D. Increase the PCA dose to address the patient's pain complaint
Correct Answer: B
Rationale: The combination of decreased JP output despite fluid accumulation (expanded
bulb), increased pain, and subtle stoma color change suggests possible internal fluid
collection/hematoma causing compression on the stoma's blood supply or the surgical
anastomosis. The priority is to ensure drain patency (milking/stripping the tubing) to relieve
pressure and immediately notify the surgeon, as this may indicate a developing complication
requiring intervention. Option A delays necessary intervention. Option C is
inappropriate—warm compresses do not address vascular compromise from external
compression and may mask deterioration. Option D treats the symptom (pain) without
investigating the cause, which could be anastomotic leak or ischemia. This requires
interdisciplinary communication with the surgical team stat.
Q3: The nurse is reviewing the PCA usage and pain assessment. Mr. Flores has used 8 mg of
hydromorphone in the past 24 hours via PCA with a 0.2 mg demand dose and 10-minute
