A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility.
Which of the following data should the nurse record on this type of document?
Daily weight, blood pressure, and pulse
Medication administration record.
Nursing diagnosis and care plan.
Discharge planning and referral summary.
The Correct Answer is A
Daily weight, blood pressure, and pulse.
A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc. A flow sheet is useful for clinical communication and tracking the patient’s condition over time. A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time. A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them. A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.
These documents are not part of a flow sheet.
Choice B is wrong because a MAR is not a flow sheet.
Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.
Choice D is wrong because a discharge planning and referral summary is not a flow sheet.
Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition. However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration. Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children. Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.
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Correct Answer is D
Explanation
Narrative charting.
This type of documentation is an example of narrative charting because it chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift in a descriptive format.
Some other choices are:.
• Choice A is wrong because SOAP charting is a type of documentation that is organized by four categories: Subjective, Objective, Assessment, and Plan.
It is commonly used in problem-oriented medical records.
• Choice B is wrong because PIE charting is a type of documentation that uses three categories: Problem, Intervention, and Evaluation.
It is based on the nursing process and eliminates the need for a separate care plan.
• Choice C is wrong because Focus charting is a type of documentation that uses three categories: Data, Action, and Response.
It emphasizes the patient’s concerns, problems, or strengths rather than medical diagnoses.
Normal ranges for vital signs and laboratory values may vary depending on the facility and the patient’s condition.
However, some general ranges are:.
• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).
• Pulse: 60 to 100 beats per minute.
• Respirations: 12 to 20 breaths per minute.
• Blood pressure: 120/80 mmHg or lower.
• Oxygen saturation: 95% or higher.
• Hemoglobin: 12 to 18 g/dL for men, 11 to 16 g/dL for women.
• Hematocrit: 37% to 49% for men, 36% to 46% for women.
• White blood cell count: 4,000 to 11,000 cells/mm3.
• Platelet count: 150,000 to 400,000 cells/mm3.
• Blood glucose: 70 to 110 mg/dL.
Correct Answer is C
Explanation
Focus.
Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.
The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.
Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.
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