When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, “Three days ago.”. Which action should the PN implement first?
A.
Administer a prescribed PRN stool softener.
B.
Encourage client to ambulate more frequently.
C.
Recommend increasing high fiber foods daily.
D.
Determine the client’s usual bowel pattern.
The Correct Answer and Explanation is:
The correct answer is:
D. Determine the client’s usual bowel pattern.
Explanation:
When assessing a client who reports having had a bowel movement three days ago, the practical nurse (PN) should first determine the client’s usual bowel pattern. This step is crucial for several reasons:
- Baseline Establishment: Understanding the client’s typical bowel habits helps in distinguishing between what is normal for the individual and what constitutes a significant change. This baseline information will guide the nurse in assessing whether the client’s current pattern is unusual or indicative of a problem.
- Accurate Assessment: The normal frequency of bowel movements can vary greatly among individuals. While some people may have bowel movements multiple times a day, others may have them every few days. Establishing the client’s usual pattern helps in identifying whether a delay of three days is a deviation from their norm or if it might be considered normal for them.
- Individualized Care: By determining the client’s usual bowel pattern, the PN can provide more personalized and effective interventions. For instance, if the client’s normal pattern is to have a bowel movement every day, then a three-day delay might be more concerning and warrant more immediate action compared to a client who typically has bowel movements every few days.
- Appropriate Interventions: Once the PN has established the client’s usual bowel pattern, they can better decide on appropriate interventions. For example, if the delay is unusual for the client, the PN might then consider options such as administering stool softeners, encouraging increased fiber intake, or recommending more frequent ambulation based on the overall assessment.
The other options, while potentially relevant, should be considered after understanding the client’s usual bowel pattern:
- A. Administering a prescribed PRN stool softener might be necessary if constipation is determined, but first understanding the baseline is essential to evaluate if the stool softener is needed.
- B. Encouraging increased ambulation and C. Recommending increased fiber intake are both beneficial for gastrointestinal health but should be guided by the client’s usual pattern and specific needs identified through assessment.
In summary, determining the client’s usual bowel pattern is the most effective first step to ensure that any actions taken are appropriately tailored to the client’s individual needs and normal physiological patterns.