A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min.

Which of the following abbreviations should the nurse use?

(Select all that apply.).

“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.

• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.

• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.

• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.

• Documenting in a timely manner to minimize errors and omissions.

The other choices are wrong because:.

• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.

• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.

• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.

Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.

They may vary according to different sources and standards.

Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.

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.