The nurse is caring for a client with a newly created ostomy. After changing the ostomy appliance, which items should the nurse include when documenting the procedure?
1. How the drainage was disposed
2. Quantity of drainage recorded on output record
3. Any client participation in the procedure
4. Assessment of stoma and skin around the stoma
5. The odor of the drainage
2, 3, 4
Rationale 1: The disposal of the drainage would not need to be documented.
Rationale 2: The nurse should document how much drainage was emptied.
Rationale 3: The nurse should document the client's involvement in the procedure.
Rationale 4: The nurse should document the assessment of both the stoma and the skin around the stoma.
Rationale 5: The odor would only be documented if it were unusual.
Global Rationale: The nurse should document how much drainage was emptied, the client's involvement in the procedure, and the assessment of both the stoma and the skin around the stoma. The disposal of the drainage would not need to be documented. The odor would only be documented if it were unusual.
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