Author Question: Which of the following types of documentation is represented by this statement? Client is wheezing ... (Read 70 times)

craiczarry · **on:** Jul 22, 2018

Which of the following types of documentation is represented by this statement? Client is wheezing and experiencing some dyspnea on exertion.

a. The S in SOAP documentation
b. Focus documentation
c. The P of PIE documentation
d. The R in DAR documentation

Question 2

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation?

a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patient's lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds present in all four quadrants.

brittanywood · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
The statement is an example of the P of PIE documentation because it describes the client's problem.
The S in SOAP documentation represents subjective data (verbalizations of the client).
Focus charting does not concentrate on problems only.
The R in DAR documentation is the response of the client. This situation describes the client's problem, not the client's response.

Answer to Question 2

A
The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.