The nurse is documenting assessment findings of a 37-year-old male with abdominal pain. Which is the most appropriate manner of documenting patient’s symptoms?

Patient reported pain of 8 on a scale of 1-10. Pain is considered to be the fifth vital sign and as such must be documented objectively and thoroughly. The nurse utilizes a pain scale to objectively document the patient’s pain. The nurse can document that the patient said he is in pain, guarding behavior is observed, and the patient asked for painkillers, but this is incomplete documentation because it does not objectively assess the patient’s pain level.

The nurse is documenting assessment findings of a 37-year-old mal...

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Management of Care
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Category: Management of Care
Difficulty: 4

Topics: Communication & Documentation Health Care Ethics, Law, and Policy Health Promotion

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