When using the PIE format for documentation, which of the following elements should the nurse include under 'P?
Problem identified during assessment
Interventions planned for the patient
Patient's subjective complaints
Evaluation of care provided
The Correct Answer is A
A. Problem identified during assessment. This is correct because in the PIE documentation format, "P" stands for "Problem," which refers to the nursing diagnosis or issue identified based on assessment findings. This section describes the primary concern that requires intervention.
B. Interventions planned for the patient. This is incorrect because interventions are documented under the "I" (Intervention) section of the PIE format, which outlines the nursing actions taken to address the identified problem.
C. Patient’s subjective complaints. This is incorrect because subjective complaints contribute to the assessment but do not represent the complete "Problem" component of the PIE format. The problem should be stated as a nursing diagnosis or issue based on assessment data.
D. Evaluation of care provided. This is incorrect because evaluation belongs under the "E" (Evaluation) section of the PIE format, which describes the patient's response to the interventions provided.
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Related Questions
Correct Answer is C
Explanation
A. While delegation is important, it occurs after the nurse establishes patient-centered goals and a care plan.
B. Evaluating the effectiveness occurs later in the nursing process. The nurse must first set goals and interventions before assessing their outcomes.
C. After analyzing data, the next step in the nursing process is planning, which includes setting measurable, individualized goals for the patient.
D. Discharge planning is important but comes later. The nurse must first establish patient goals and care priorities before involving other healthcare team members.
Correct Answer is B
Explanation
A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.
B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.
C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.
D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.
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