Question

CRITICAL THINKING ACTIVITIES 1 Compare the six different forms of documentation and choose the one that seems to you to be the most logical and easy to use. Describe two advantages and two disadvantages of this type of documentation 2. Part of documentation is nursing care planning. From the following scenario, list the assessment data, define the main problem in the form of a nursing diagnosis, and write an expected outcome. June Tully, age 22, was involved in an automobile accident. She arrives via ambulance at the emergency department. She is able to answer questions and can follow commands, although she is strapped to a backboard to prevent spinal movement. Her pupils are equal and reactive to light. X-rays show a frac- ture of her right femur and she is unable to move her right leg without excruciating pain. There is a lac- eration on her right wrist. She complains of pain in the right wrist. Assessment data Nursing diagnosis Expected outcome

Answer 1

1.The different types of documentation in healthcare field are

• Medical records
• Nursing documentation
• Discharge card or Discharge summary
• Diagnostic /Laboratory documentation
• Surgical documentation
• Consents
• Mental status examination

Discharge summary is one of the documentation which is prepared on the basis that even a lay man can understand and use it because patients can make use of it after discharge to know about the medication history to be done,follow up etc.,

The disadvantage is trying to get medication as OTC drug by knowing the action of medication due to knowledge of the mefication prescribed

2.Assessment :

• Subjective data
  • Pain in wrist
• Objective data
  • Verbalisation of pain
  • Right femur fracture on X Ray
  • Laceration on right wrist
  • Unable to move right leg
  • Pupils:equal and reacting to light
• Nursing Diagnosis
  • Acute pain (in right femur) related to loss of skeletal continuity  as evidenced by pain, verbalisation,fracture
• Expected outcome
  • Will be relieved from pain by proper fracture alignment or corrections