A nurse is using a flow sheet to document the care of a client who has heart disease and is admitted to a long-term care facility.
Which of the following data should the nurse record on this type of document?
A.
Daily weight, blood pressure, and pulse
B.
Medication administration record.
C.
Nursing diagnosis and care plan.
D.
Discharge planning and referral summary.
The Correct Answer and Explanation is:
The correct answer is A. Daily weight, blood pressure, and pulse.
Explanation:
A flow sheet is a type of document used in nursing and healthcare settings to record and track various types of data over time. It is particularly useful for monitoring changes in a patient’s condition and for providing a clear, concise record of ongoing observations and interventions. In the context of a long-term care facility, a flow sheet is typically used to capture routine measurements and vital signs that are critical for managing chronic conditions, such as heart disease.
Why Option A is Correct:
Daily weight, blood pressure, and pulse are key vital signs and metrics that should be regularly monitored and documented for a client with heart disease. Heart disease often requires meticulous tracking of these parameters to manage symptoms, assess the effectiveness of treatment, and detect any worsening of the condition.
- Daily Weight: Monitoring weight is crucial because sudden changes can indicate fluid retention or loss, which can be a sign of worsening heart failure or other complications.
- Blood Pressure: Blood pressure is a critical measure in heart disease management as both hypertension and hypotension can impact heart function and overall health.
- Pulse: Regular monitoring of the pulse helps in assessing the heart rate and rhythm, which are important for evaluating the cardiac condition and the effectiveness of medications.
Why Other Options Are Less Appropriate:
- Option B (Medication administration record): This record is typically part of a medication administration record (MAR), not a flow sheet. The MAR specifically tracks medication administration details such as dosages, timings, and any adverse reactions.
- Option C (Nursing diagnosis and care plan): While nursing diagnoses and care plans are crucial for guiding patient care, they are usually documented in care plans rather than flow sheets. Flow sheets focus on monitoring and tracking data rather than creating or updating care plans.
- Option D (Discharge planning and referral summary): Discharge planning and referrals are part of discharge documentation and care transition planning, not routine monitoring. These details are not typically recorded on flow sheets, which are used for ongoing clinical data tracking.
In summary, option A aligns with the purpose of a flow sheet in providing a systematic approach to monitoring and recording essential clinical parameters for a patient with heart disease.