Which of the following demonstrates appropriate nursing documentation?

Patient''s left lower lobe has coarse crackles
Stage II pressure ulcer noted on sacrum, measuring 4 cm across, erythematic, Mepilex dressing in place

Explanation

•Documentation should be objective and only include findings that are smelled, seen, felt, or heard.

•Pressure ulcer documentation should include the size, location, stage, exudates and other objective descriptors.

•Drawing conclusions about a patient's feelings or thoughts is not appropriate documentation.

•Documenting that the patient had a terrible night is not precise enough.

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