5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

• Abdominal distension.
• Abnormal bowel sounds — hypoactive, hyperactive, or absent.
• Tenderness, guarding, rigidity, or rebound (an acute abdomen), or a palpable mass.
• Constipation — no bowel movement, hard stool, or impaction risk, especially on opioids — or diarrhea.
• Nausea or vomiting, including bilious, bloody, or coffee-ground emesis.
• GI bleeding — hematemesis, melena, or hematochezia — an emergency, especially on anticoagulation.
• Ostomy complications — an ischemic, retracted, or prolapsed stoma, high or absent output, peristomal skin breakdown, or leakage.
• Dysphagia (with Taste / Swallowing).