A 47-year-old patient who is 3 days postsurgery with a permanent colostomy reports some abdominal discomfort and abdominal rigidity. The assessment that the nurse should report and record is:
1. vital signs—temperature, 100; pulse, 92; blood pressure, 160/98.
2. stoma is swollen and red; small amount of blood at base.
3. pouch drainage of 110 mL green-brown liquid, oozing from pouch edges.
4. stoma is protruding.
1
Vital signs in conjunction with complaint of abdominal discomfort should be reported and recorded as possible signs of impending peritonitis.
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