A child has a postoperative appendectomy incision covered by a dressing. The nurse has just completed a prescribed dressing change for this child. Which description is an accurate documentation of this procedure?
a. Dressing change to appendectomy incision completed, child tolerated procedure well, parent present
b. No complications noted during dressing change to appendectomy incision
c. Appendectomy incision non-reddened, sutures intact, no drainage noted on old dressing, new dressing applied, procedure tolerated well by child
d. No changes to appendectomy incisional area, dressing changed, child complained of pain during procedure, new dressing clean, dry and intact
ANS: C
The nurse should document assessments and reassessments. Appearance of the incision described in objective terms should be included during a dressing change. The nurse should document patient's response and the outcomes of the care provided. In this example, these include drainage on the old dressing, the application of the new dressing, and the child's response. The other statements partially fulfill the requirements of documenting assessments and reassessments, patient's response, and outcome, but do not include all three.
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