A resident in a nursing home complains of constipation. The nurse checks the patient record and notes that he has not had a bowel movement in three days. She/he then performs a digital rectal exam and feels hard stool. Which part of the nursing process is this?
A.
evaluation
B.
assessment
C.
nursing diagnosis
D.
implementation
The Correct answer and Explanation is:
The correct answer is B. assessment.
Explanation:
The nursing process is a systematic approach that guides nurses in providing patient care. It consists of five key steps: assessment, diagnosis, planning, implementation, and evaluation. Each step plays a crucial role in ensuring comprehensive and effective nursing care.
In the scenario presented, the nurse is dealing with a resident who has not had a bowel movement in three days and is experiencing constipation. The first action the nurse takes is to check the patient record for relevant information. This is an initial part of the assessment phase, where the nurse gathers data about the patient’s condition. Following this, the nurse performs a digital rectal exam, which is a physical assessment technique used to identify the presence of hard stool in the rectum.
The assessment phase involves collecting subjective and objective data to understand the patient’s health status. Subjective data may include the patient’s reported symptoms, such as discomfort or the feeling of not having a bowel movement, while objective data includes physical findings like the hardness of the stool discovered during the rectal exam. This comprehensive data collection is essential as it lays the groundwork for the next steps in the nursing process.
Once the assessment is complete, the nurse will analyze the gathered information to identify nursing diagnoses related to the patient’s constipation, such as “Constipation related to inadequate dietary fiber intake.” Subsequently, the nurse can plan appropriate interventions to address the issue, implement these interventions, and then evaluate their effectiveness.
In summary, the actions of checking the record and conducting a digital rectal exam are integral to the assessment phase of the nursing process, as they focus on gathering and analyzing data necessary for guiding patient care decisions.