Question

A client develops steatorrhea with malabsorption syndrome. How will the nurse document this finding in the client’s medical record?

Answer 1

Steatorrhea is the presence of fat in a person's fecal material.  This is due to some malabsorption syndrome going on in his or her lower gastro-intestinal area.  Nurses' notes must contain the following ingredients--initial assessment, time of any change noted in client's condition, care provided, and other relevant information that will serve as helpful information to other members of the healthcare team.  Hence, the nurse's note can be worded as follows:  (TIME) The patient is (conscious or lethargic) on (bed or chair) and requested to defecate on the (commode or toilet).  Noticed (amount) of fats in feces.  Cleaned patient and made comfortable on (bed or chair).  Informed healthcare provider about the incident.