Question

The nurse is caring for a patient who has been diagnosed with pneumonia. The nurse is reviewing the assessment details of the patient: Blood pressure is 150/90 mm Hg; pulse is 92 beats/minute, and the respiratory rate is 22 breaths/minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning. A senior nurse finds this to be poor quality of documentation. Which statements in the documentation are considered to be poor quality documentation and informatics? Select all that apply.

a) Vital signs: blood pressure 150/90 mm Hg, pulse rate 92 beats/minute, and respirations 22 breaths/minute.

b) The patient seems to have difficulty breathing.

c) Auscultation reveals rhonchi in the lower lung bases.

d) Sounds are produced when exhaling.

e) Copious amounts of sputum produced since morning

Answer 1

In a patient with pneumonia, poor quality documentation includes subjective and vague statements like 'difficulty breathing' and 'sounds produced when exhaling'. However, noting vital signs, specific breath sounds like rhonchi, and describing the quantity of sputum are examples of good documentation practice.

Step-by-step explanation:

In reviewing the nurse's documentation for a patient with pneumonia, certain statements can be considered as poor quality documentation and informatics. These include:

• The patient seems to have difficulty breathing. - This is subjective and lacks specificity. It would be more appropriate to describe the objective signs that contribute to this assessment, such as increased work of breathing, use of accessory muscles, or nasal flaring.
• Sounds are produced when exhaling. - This statement is vague and should be replaced with specific descriptions of the breath sounds heard through auscultation, such as wheezing, crackles, or rhonchi.

On the other hand, statements such as vital signs being provided, the specific description of rhonchi in the lower lung bases, and the note of copious amounts of sputum are examples of objective and high-quality documentation.