The nurse is documenting the care of a patient. Which entry would be characteristic of charting by exception (CBE) as a documentation method?
a. The patient needed to be turned every hour because of increasing pain.
b. The patient's vital signs are stable.
c. The patient's gait was steady with assis-tance from physical therapy.
d. There was no odor when the dressing was removed.
A
CBE allows the nurse to specify exceptions to normal nursing assessments efficiently without documenting the normal assessment data and reducing the amount of narrative writing in patient documentation. The emphasis is on recording abnormal findings and trends in clinical care. It is a shorthand method for documenting based on defined standards for normal nursing assessments and interventions. CBE simply involves completing a flow sheet that incorporates these stan-dards, thus minimizing the need for lengthy narrative notes. Increasing pain would not be ex-pected and would be outside the "normal" or "expected.".
You might also like to view...
What should the nurse focus on when creating a nursing care plan for a patient with metabolic acidosis?
a. Frequent periods of ambulation b. Increasing fluid intake c. Decreasing fluid intake d. Deep-breathing exercises
A nurse demonstrates understanding of the continuity theory when the nurse provides which of the following advice to an older client? (Select all that apply.)
a. "It is important to think about the activi-ties that have been most satisfying for you throughout your adult life and make a plan to continue them" b. "Since you enjoyed teaching young chil-dren so much, perhaps you would enjoy volunteering in the day care center" c. "It is important to save enough money so that you will have an adequate income during retirement" d. "It is important to maintain an active life-style as you age" e. "As you get older it is natural to slowly disengage oneself from many activities"
The individual qualities that make the person unique are called ____________________
Fill in the blank(s) with correct word
A nurse is caring for a female client with anorexia nervosa. What would the nurse observe during the nursing assessment of the client?
A) Menorrhagia B) Rapid pulse C) Alopecia D) Hypertension