The registered nurse (RN) and licensed practical nurse (LPN) are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? Select all that apply.
A.Assess perfusion of the stoma tissue
B. . Assist the client in changing the ostomy pouch
C. Auscultate the client’s bowel sounds
D. Develop plan of care to prevent skin breakdown 5. Monitor the color of ostomy drainage
The Correct Answer and Explanation is:
The correct answer is: 2. Assist the client in changing the ostomy pouch and 5. Monitor the color of ostomy drainage.
Explanation:
Delegation in nursing requires understanding the differences in roles and responsibilities between Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). The RN generally has a broader scope of practice, including tasks requiring critical thinking, assessment, and planning, while the LPN often performs tasks that are more procedural or assistive in nature. In this case, since the client has an established colostomy (one that is already healed and functional), the RN may delegate certain routine care tasks related to ostomy management to the LPN.
- Option 1: Assess perfusion of the stoma tissue
This task requires the assessment of tissue perfusion, which involves critical thinking and interpretation skills. Assessing stoma perfusion entails observing for signs such as color, temperature, and moisture to determine if blood flow is adequate. Since LPNs cannot conduct initial or complex assessments, this responsibility falls under the RN’s scope of practice. - Option 2: Assist the client in changing the ostomy pouch
Changing an ostomy pouch is a routine task that an LPN can perform. While the LPN can carry out the physical process of changing the pouch, they should report any unusual findings to the RN. Assisting with the pouch change also provides the LPN an opportunity to reinforce self-care practices if the client is managing the colostomy independently. - Option 3: Auscultate the client’s bowel sounds
Auscultation of bowel sounds is an assessment task, requiring the ability to interpret findings within the context of the client’s overall condition. Since it involves clinical assessment, it is within the RN’s responsibility rather than the LPN’s. - Option 4: Develop a plan of care to prevent skin breakdown
Developing a plan of care involves creating individualized interventions based on the client’s needs, assessment findings, and clinical judgment. This process requires higher-level critical thinking and is solely within the RN’s scope. - Option 5: Monitor the color of ostomy drainage
Monitoring the color of ostomy drainage is an observational task suitable for the LPN. The LPN can observe and record the drainage characteristics, such as color and consistency, which can indicate changes in the client’s condition. Any unusual findings should be reported to the RN for further assessment and action.
In summary, options 2 and 5 are tasks that fall within the LPN’s scope, as they involve assisting the client and monitoring routine aspects of care. Options 1, 3, and 4 are assessment and care-planning tasks that require the RN’s expertise and critical thinking skills.