Practice Documenting: Bowel and Bladder

You are working the night shift. During report you learned that one of your clients, Booker, had not eaten any dinner and had been complaining about stomach cramps. On your first round at about 2315 you check on Booker to see how they are doing. Booker says, “I think I need to use the restroom. I do not feel well.” You help them with their slippers and use a gait belt to assist them to the restroom. Once in the restroom Booker voids. After being on the toilet for about 5 minutes they state, “I think I am done, can you help me back to my bed?” You do so. Before leaving you go into the restroom and note that they have voided in the toilet and that it is a dark yellow color. At 0100 Booker’s call light turns on. You go to the room and Booker requests to use the toilet immediately. Once there Booker has a large bowel movement that is brown with red streaks, soft and mushy. You assist Booker with cleaning up and then assist them back to bed. At 0230 Booker’s call light comes on once again. Booker needs to use the restroom urgently. You assist Booker to the toilet. At that time Booker has a large liquid bowel movement that is brown with red flecks. At 0430 Booker’s call light comes on one more time. Once again Booker needs to use the restroom promptly. This time Booker does not have a bowel movement but voids urine that is dark yellow. At 0630, your last check on Booker, they are sleeping comfortably.

How would you document Booker’s bowel and bladder?