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Diane is a nurse who is providing care to Mr. Brown. The scenario describes their interaction and the information that she entered into the chart.

 

Mr. Ron Brown is a 71 year- an old gentleman with Type 1 diabetes admitted to the hospital for treatment of an ulcer on his right heel. Diane was assigned to Mr. Brown and Diane also provided nursing care to him yesterday. Mr. Brown was alert and oriented to person, place, and time. He normally had no problems with ambulation. Mr. Brown wears glasses to read and drive and he has no hearing deficits. He lives alone. Mr. Brown’s discharge plan is to return to his apartment. During her morning assessment, Diane noted at 0800 that Mr. Brown had some facial grimacing and he limped on his right foot when he walked to the bathroom. When asked, Mr. Brown tells Diane “I have pain where the ulcer is”. Diane probed further to determine the characteristics of Mr. Browns’ pain as constant and throbbing, and he rated it’s intensity as 6 out of 10. Diane administered pain medication (Tylenol #3- 2 tablets) at 0830. Diane reassessed Mr. Brown’s pain at 0945 and he rated the intensity at 1 out of 10. Diane decided to do Mr. Brown’s dressing change at 0950 since Mr. Brown’s pain was controlled. When Diane removed the old dressing Diane noted a moderate amount of fresh watery, bloody drainage with a small amount of green-yellow pus drainage. The ulcer area was “round” and the size was about 3 cm x 4 cm, the area around the ulcer was red. The ulcer borders were well defined. Most of the wound bed was granulation tissue with a smaller amount of yellow slough. Mr. Brown had decreased sensation to this area of his foot as he could not feel the coolness of the solution or feel when Diane was pressing down. An adaptive dressing, 2- 4×4 gauze, and ½ abdominal pad were placed on the wound. Mr. Brown did not complain of any discomfort during the dressing change. Diane entered the following documentation in Mr. Brown’s record: 

0815 Client reports pain right foot Diane Smith, R.N.
0830 Tylenol #3 two tabs given for complaints of pain. Diane Smith, R.N.
0950

Dressing to right foot changed for moderate amount of bloody Diane Smith, R.N. drainage with some pus. The wound looks clean and healing. The client client tolerated the dressing change well.

 

Diane Smith, R.N.

 

Critique Diane’s documentation on the care she provided to Mr. Brown. Identify what she did well, and the areas where she could improve her documentation using the characteristics of effectivea 
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