Kozier & Erb's Fundamentals of Nursing 10th Edition by Shirlee Snyder,Audrey Berman,Geralyn Frandsen

Exercise 1

Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse:
8-Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12-Refused lunch.
2-Client fell out of bed.
What guidelines were not used in this documentation?