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Kozier & Erb's Fundamentals of
Nursing
(10th Edition) Edit edition

This problem has been solved:

CH15 1CTC

Mr. Anderson, an 80-year-old male, was

admitted for back pain. He has a past medical
history of hypertension. He told the admitting
nurse that he has lost interest in many of his
normal activities because of the constant pain.
You read the following documentation entry by a
previous nurse:
8—Client is a complainer. I listened to him for 15
minutes with no success. BP 210/90 and 180/70.
P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
What guidelines were not used in this
documentation?

Step-by-step solution:

Step 1 of 4
The quality of the client care is dependent on
effective documentation and communication of
the client's details. The client's physiological and
mental details are documented or recorded
digitally and manually. This procedure should be
very sensitive, detailed, accurate and con"dential
to ensure legal quali"cation.
According to the case presented, Mr. Anderson,
an 80-years-old male, has been presented with
acute pain. He has a health history of
hypertension and reports of fatigue and lethargy
associated with the continuous pain.

Step 2 of 4
Following are the guidelines for documenting
that were not followed in the presented
documentation:
1. Date and time: The date of documenting the
assessment of the patient has not been
mentioned. Only the time of each recording has
been provided.
2. Inappropriate timing: The documentation
should have been more frequent as the client
has a rapidly #uctuating blood pressure.
3. A certain change in a physiological condition
should be recorded as soon as the nursing
intervention has been implemented, which is
absent or uncertain in the documentation
presented.

Step 3 of 4
4. The documentation should contain a chart
showing the physiological changes and the
corresponding follow-up actions that have been
taken.
5. The comments of the client should be quoted
word by word, not to be narrated in the
documentation.
6. The nurse should not use words such as
‘complainer’ and ‘disagreeable’ in the
documentation because these words re#ect
prejudice.

Step 4 of 4
7. “Client fell out of bed” is a vague and non-
speci"c record. The record should contain
speci"c, objective and factual information.
8. The documentation lacks the client’s response
to the nursing interventions.

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Corresponding Textbook

Kozier & Erb's

Fundamentals of
Nursing | 10th Edition
ISBN-13: 9780133975161
ISBN: 0133975169
Authors: MSN Frandsen
EdD, Audrey T.
Berman,
Shirlee Snyder

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Kozier & Erb's Fundamentals of Nursing

(10th Edition)
Solutions for Chapter 15

Solutions for Problems in

Chapter 15 is solved

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