The nurse is charting on his client, who had an open appendectomy the previous day. Which are appropriate nursing documentation entries?

Select all that apply.
  1. The client appeared anxious when several family members came to visit.
  2. The client appeared angry when the health care provider changed her medications.
  3. The client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping.
  4. The abdominal dressing is clean, dry, and intact with a 3-cm area of light staining noted in the center.
  5. The client ambulated 200 feet in the hall with a cane. No dyspnea or syncope noticed. Tolerated well.
Numbers 3, 4, and 5 are correct.
Rationale: Charting should always contain only objective facts regarding what the nurse sees, hears, or feels. Noting that the client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping is an objective observation. It is important to note how well the client tolerated the meal. If the client complained of nausea while eating, this observation would be noted, preferably in the client’s own words, such as “I started to get nauseated when I tried to eat.” The observation about the abdominal dressing is factual and objective, noting the size of the area of light staining. When a client ambulates in the hall, it is important to chart the distance, whether assistive devices were used, and how well the client tolerated it. The nurse states that no dyspnea or syncope was noted. Statements that the client appeared anxious when family came to visit infers that the client was anxious due to the family’s visit. This is presumptive on the nurse’s part, as the client could be appearing anxious from unvoiced thoughts. Likewise, the nurse makes it sound as if the client is angry because her medications were changed, when there is no evidence that this is the case. The nurse should avoid charting that a client “appears” to have a certain type of reaction to an event, and chart only those objective facts without speculation.