A nurse is teaching a newly licensed nurse about preventing puncture injuries, Which of the following instructions should the nurse include?

A) Heart failure:
While heart failure can cause a variety of symptoms, including shortness of breath, fatigue, and nocturnal respiratory disturbances, it is not a direct cause of obstructive sleep apnea (OSA). However, heart failure can exacerbate the effects of sleep apnea, particularly in individuals who already have OSA, leading to a condition known as "central sleep apnea with Cheyne-Stokes respiration.

B) Brainstem injury:
Brainstem injury can affect the regulation of breathing and may lead to central sleep apnea, where the brain fails to send the proper signals to the muscles that control breathing. However, brainstem injury does not directly cause obstructive sleep apnea, which is typically caused by physical blockages or obstructions in the upper airway.

C) Recent weight loss:
Recent weight loss is generally not associated with the development of obstructive sleep apnea. In fact, weight loss can sometimes reduce the severity of OSA in overweight or obese individuals. OSA is more commonly associated with excess weight and fat deposits around the neck and throat, which can contribute to airway obstruction during sleep.

D) Enlarged tonsils:
Enlarged tonsils, especially in children, are a well-known cause of obstructive sleep apnea (OSA). The enlarged tonsils can block the upper airway during sleep, leading to periods of apnea or hypopnea (reduced airflow). This obstruction can result in snoring, choking, and interrupted sleep.

A) SOAP documentation:
SOAP (Subjective, Objective, Assessment, Plan) documentation is a method used for organizing and documenting client information. It focuses on both subjective and objective data, as well as the assessment and plan. While SOAP helps structure the documentation of patient conditions and interventions, it does not specifically focus on documenting only unexpected findings. It is a more comprehensive approach that includes normal and abnormal findings, not just the unexpected ones.

B) Focus charting (DAR):
Focus charting (DAR) is based on a client-centered approach and uses the components of Data, Action, and Response. It is a way of documenting observations and interventions, particularly in relation to specific patient problems or conditions. Focus charting is more about the care provided, responses to interventions, and client outcomes. While it may include unexpected findings, it doesn’t limit documentation exclusively to abnormal or unexpected events.

C) Charting by exception (CBE):
Charting by exception (CBE) is a documentation method that focuses on recording only the significant deviations from the norm. It emphasizes noting any abnormal or unexpected findings, and everything that is normal is assumed to be within expected limits and not documented. This method reduces the amount of documentation by excluding routine information and only highlighting significant, unexpected findings. Therefore, CBE is the correct answer in this scenario, as it involves documenting only unexpected or abnormal findings related to the client's condition.

D) Problem-oriented medical record (POMR):
POMR is a method of documentation that organizes client care around specific problems or diagnoses. It includes the identification of problems, interventions, and outcomes. While POMR focuses on client problems and plans of care, it does not specifically focus on documenting only unexpected findings. It may include both normal and abnormal findings related to each identified problem.