A patient refuses a prescribed dressing change. Which documentation is most appropriate?
Correct answer: B. Patient refuses dressing change and states, “It is too painful”
- A. Patient is difficult and refuses necessary care
- B. Patient refuses dressing change and states, “It is too painful”
- C. Patient is noncompliant and does not understand treatment
- D. Dressing change was omitted because the patient was uncooperative
Explanation
Documentation should state the patient's action and exact reason without judgmental labels. The nurse should also assess the pain, explain the procedure and report or record the refusal according to policy.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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