The nurse is providing ostomy care for a client with a colostomy. Which assessment findings should the nurse report to the health care provider if noted during the procedure?
1. No change in stoma size
2. A stoma that appears dry and grey in color
3. The presence of skin irritation
4. The amount of drainage
5. The odor of the drainage
2, 3
Rationale 1: No change in the size of the stoma is a normal finding that does not require reporting to the health care provider.
Rationale 2: Findings that are abnormal include a stoma that is dry and grey in color, as this indicates circulatory impairment.
Rationale 3: Findings that are abnormal include the presence of skin irritation.
Rationale 4: The amount of drainage is documented but not reported unless there is a problem.
Rationale 5: Odor is not reportable and is only documented if a change is noted.
Global Rationale: The nurse would report abnormal assessment findings to the health care provider if noted when providing ostomy care to the client. Findings that are abnormal include a stoma that is dry and grey in color, as this indicates circulatory impairment, and the presence of skin irritation. No change in the size of the stoma is a normal finding that does not require reporting to the health care provider. The amount of drainage is documented but not reported unless there is a problem. Odor is not reportable and is only documented if a change is noted.
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