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A nurse is listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury. How does the nurse document this type of assessment?

User Wilson
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Final answer:

The nurse would document family discussions regarding feelings such as guilt and anger in an objective manner as part of the patient's medical record. They would also participate in team reviews, confirming procedural aspects like specimen labeling and equipment status. Additionally, neurological examinations or public health investigations may be part of the overall assessment.

Step-by-step explanation:

When a nurse is documenting the assessment of family members' feelings regarding a patient's condition, they must provide accurate and professional observations. The nurse would record family members discussing feelings of guilt and anger associated with the patient's traumatic brain injury in the patient's medical record, describing the emotional state and concerns expressed by the family.

It's important to include objective descriptions without making subjective judgments. This documentation might resemble an ethnographic study in which the cultural and social reactions are noted alongside the clinical scenario.

For instance, the nurse might document: "Family members expressed feelings of guilt and anger over the course of the patient's recovery." They might also note any specific concerns raised by the family that could impact the patient's care plan or indicate a need for additional support services, such as counseling or pastoral care.

In the context of a medical team, the nurse reviews items aloud with the team, including confirming the proper labeling of specimens and the completeness of counts for needles, sponges, and instruments, as well as addressing any equipment issues. This ensures a collective understanding and reinforces patient safety protocols.

If necessary, further neurological examination of the patient may be conducted by following specific procedures, such as asking the patient to perform tasks that help determine their sensory and motor functions, potentially leading to further actions such as a CT scan or specific therapy. Public health professionals like epidemiologists may also review medical records and conduct interviews with patients as part of their investigations.

User Cella
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