A 52-year-old man with a T10 spinal cord injury resides in a long-term care facility on an intermittent urinary catheterization and bowel management protocol. The LPN notes his indwelling urinary catheter has drained only 80 mL of dark, concentrated urine over the past 6 hours, though he received 900 mL of oral fluids and 250 mL of tube feeding during that time. He has had no bowel movement in 3 days despite scheduled suppository use. His sacral skin is intact but reddened over the coccyx, and his Braden Scale score is 14, indicating moderate risk. He has remained in the same side-lying position for the past 4 hours. Which action should the nurse take first?
- Continue the current bowel and bladder protocol without changes and recheck output next shift.
- Note the findings for the next shift and proceed with the scheduled comfort care routine.
- Reposition the client off the reddened area now and report the urine output to the RN.
- Estimate the intake and output totals in the chart to save time and finish other tasks.