A nursing student documents the following entries after providing care for the client. Which entry should the student revise?
A) Midline abdominal incision, approximately 3 inches in length is open to air with staples well approximated, and no redness, edema, or drainage present.
B) Client smells like rotten eggs, is visibility filthy, and is uncooperative with staff trying to bathe him and stated he wants to be left alone, and appears depressed.
C) Complaint of stabbing pain in lower back radiating down right leg, rated 5 out of 10 on pain scale, and requests pain medication.
D) Lungs are clear to auscultation anteriorally and posteriorly with easy, even, nonlabored respirations; no complaint of pain, discomfort, or shortness of breath.
Ans: B
Feedback:
When charting nursing care, the nurse should record concise, accurate findings and avoid personal opinion. The nurse should not provide a personal opinion about the client's odor, appearance and uncooperative manner. A better way to chart the information would be the following: Refuses staff to bathe him and stated he wants to be left alone. When charting about the client, it is implied it is about the client, so the word "client" may be omitted.
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