N2

Opioid bowel regimen effective

Skilled gastrointestinal assessment completed for a patient on a scheduled opioid. The bowel regimen is effective — a bowel movement every one to two days of normal consistency — with a soft, non-tender abdomen and normoactive bowel sounds; no distension or impaction concern. Findings indicate effective constipation prevention on opioids. RN-level assessment was required to evaluate bowel function on the opioid regimen and screen for constipation and impaction. The bowel regimen — fluids, fiber, activity, and the prescribed agents — reinforced; teach-back accurate. Continued skilled monitoring indicated. (Opioid regimen in the Pain reference.)

N3

Ostomy healthy, care competent

Skilled gastrointestinal assessment completed for a patient with a colostomy. The stoma is beefy-red and viable, output is formed and of appropriate volume, the appliance is well sealed without leakage, and the peristomal skin is intact. Findings indicate a healthy ostomy with effective care. RN-level assessment was required to evaluate stoma viability, output, and peristomal skin and confirm competent management. The appliance change and skin monitoring reinforced; the caregiver completed a return demonstration accurately. Continued skilled monitoring indicated. (Device detail in the Lines / Drains / Devices reference.)

N4

Recovering GI function post-op

Skilled gastrointestinal assessment completed at the post-operative visit. Bowel function has returned — the patient is passing flatus and has had a bowel movement — with a soft, appropriately tender-at-the-incision abdomen, normoactive bowel sounds, and no distension or signs of obstruction or bleeding. Findings reflect expected post-operative recovery. RN-level assessment was required to confirm the return of bowel function, screen for post-operative complications, and reassess the diet advancement. Diet advancement, activity, and warning signs reinforced; teach-back accurate. Continued skilled monitoring indicated.

N5

Nausea resolved, intake returning

Skilled gastrointestinal assessment completed after a recent bout of nausea. The nausea has resolved with the prescribed management, intake is returning, and the abdomen is soft and non-tender with normoactive bowel sounds; no vomiting and no bleeding signs. Findings reflect resolution of the nausea. RN-level assessment was required to confirm resolution against the prior symptoms, screen for complications, and coordinate the return of intake. Antiemetic use, hydration, and warning signs reinforced; teach-back accurate. Continued skilled monitoring indicated. (Intake and hydration in the Nutrition and Hydration references.)

N6

Interval GI check, stable

Skilled gastrointestinal assessment completed at the scheduled interval visit. The abdominal examination, bowel pattern, and (where present) ostomy function are unchanged and at baseline, with no nausea, vomiting, or bleeding signs. Findings stable. RN-level assessment was required to confirm the GI examination against baseline, re-screen for an acute abdomen and bleeding, and reassess bowel function given the diagnosis and medications. The bowel regimen and warning signs reinforced; teach-back accurate. Continued skilled monitoring indicated.