Which documentation entry is most appropriate after assessing a patient's wound?
Correct answer: C. Red, warm area measuring 3 cm surrounds incision
- A. Wound looks bad and patient is careless
- B. Wound is probably infected and painful
- C. Red, warm area measuring 3 cm surrounds incision
- D. Patient seems unhealthy and does not cooperate
Explanation
The third entry uses observable, measurable and neutral language, making it suitable for the clinical record. Terms such as bad, careless and unhealthy are judgmental or interpretive and do not describe specific assessment findings.
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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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