A 47-year-old patient with a permanent colostomy reports some abdominal discomfort and rigidity 3 days after surgery. Which assessment should the nurse report and record?
a. Vital signs are temperature, 100° F; pulse, 92 beats/min; and blood pressure, 160/98 mm Hg.
b. Stoma is swollen and red; small amount of blood is observed at the base.
c. Pouch has drained 110 mL of green-brown liquid, oozing from the pouch edges.
d. Stoma is protruding.
A
Vital signs, in conjunction with the complaint of abdominal discomfort, should be reported and recorded as possible signs of impending peritonitis.
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