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?

Rationale:

A. Agranulocytosis is an extreme decrease in neutrophils, which increases the risk of infection. Invasive procedures are not specifically minimized for bleeding risk but rather infection control measures are prioritized.

B. Leukopenia (low white blood cell count) increases susceptibility to infection, so precautions focus on protecting from infection, not necessarily minimizing invasive procedures due to bleeding.

C. Anemia (low red blood cell count) primarily affects oxygen-carrying capacity, leading to fatigue or dyspnea. It does not directly increase the risk of bleeding, so invasive procedures are not minimized solely for anemia.

D. Thrombocytopenia (low platelet count) increases the risk of bleeding and bruising. Minimizing invasive procedures such as injections, IV insertions, or rectal exams is critical to prevent hemorrhage or hematoma formation. This is why patients with thrombocytopenia require careful handling and sometimes platelet transfusions before necessary invasive interventions.

Rationale:

A. Before administering pain medication, the nurse must assess the client’s pain to determine its intensity, location, and characteristics. Using a standardized pain rating scale ensures accurate dosing, helps evaluate the effectiveness of interventions, and prevents under- or over-medication. Pain assessment is considered the first and essential step in pain management.

B. Nonpharmacologic methods like distraction can help manage pain, but they do not replace the need for a proper pain assessment before administering medication. These techniques are complementary interventions, not a substitute for assessment.

C. Administering medication without assessing the pain level is unsafe. It can lead to inappropriate dosing, ineffective pain relief, or adverse effects. Proper assessment guides safe and effective pain management.

D. Relaxation techniques may be helpful as adjunctive pain management, but they should not precede pain assessment. Accurate assessment is necessary to determine if pharmacologic intervention is needed and at what dose.