When using the PIE format for documentation, which of the following elements should the nurse include under 'P?
Problem identified during assessment
Interventions planned for the patient
Patient's subjective complaints
Evaluation of care provided
The Correct Answer is A
A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.
B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.
C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.
D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.
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Related Questions
Correct Answer is B
Explanation
A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.
B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.
C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.
D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.
Correct Answer is B
Explanation
A. Assessment. This is incorrect because assessment refers to the initial data collection before interventions are performed. The nurse auscultating the lungs after administering the medication is part of evaluating the effectiveness of treatment.
B. Evaluation. This is correct because evaluation involves determining whether the intervention was successful in achieving the desired outcome. The nurse is assessing lung sounds to determine if the inhaled medication improved airway clearance and breathing.
C. Diagnosis. This is incorrect because diagnosis involves identifying the patient's health problems based on assessment data. The nurse is not formulating a diagnosis in this scenario but rather checking the response to treatment.
D. Planning. This is incorrect because planning involves setting patient goals and selecting interventions before implementation. The nurse auscultating lung sounds after treatment is an evaluation step, not a planning step.
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