Answer to Question 1
A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is 5 cm in length without redness, edema, or drainage is more descriptive than large wound healing well. It is essential to know the institution's abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word daily or every day on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term no complaint may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient's status and plan of care.
Answer to Question 2
.T tube
The T tube, also called a Briggs adaptor, is a T-shaped device with a 15-mm (3/5-inch) connection that connects an oxygen source to an artificial airway such as an endotracheal (ET) tube or tracheostomy.
Methods to Document Peripheral Pulses A. Stick Figure Peripheral Pulse Documentation B. Tabular Peri
Nine Abdominal Anatomic Regions
Wound healing by tertiary intention.
Compare the Final Code with the Documentation
Abdominal muscles.
The nine divisions of the abdominal region.