Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.The nurse should:

Question

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When documenting a significant change on a flow sheet,you describe the change,including the patient response to nursing interventions,in the progress notes.For example,if a patient's blood pressure becomes dangerously low,record the blood pressure in the progress notes as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure.
Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events,

Patients on the Unit Have Their Vital Signs Taken Routinely