A nurse is caring for a patient scheduled for a colonoscopy who has orders for tap water enemas until clear.The nursing assistant administers a soap suds enema.Which of the following is the best documentation of this event?
A)"Nursing assistant gave the wrong type of enema, patient is currently stable."
B)"Soap suds enema given by nursing assistant, moderate amount liquid stool with brown flecks noted with returns.Patient denies abdominal cramping."
C)"Incident report completed due to provision of soap suds enema by the nursing assistant."
D)"Tap water enema ordered, soap suds enema given, physician notified."

Question

Quizplus · Accepted Answer

The best documentation is option B as it clearly states what happened, what was observed, and the patient's response. The incident report is not necessary for the documentation but should still be completed. Option A is not appropriate as it does not provide any useful information for the patient's care or potential follow-up. Option D is not appropriate as it implies that the physician was notified of the wrong enema being given, which is not stated in the scenario.

A Nurse Is Caring for a Patient Scheduled for a Colonoscopy