Assessment Documentation Examples

7/28/2019 Assessment Documentation Examples

1/5

Assessment Documentation Examples

Assessment Thursday Friday

General Appearance

Affect, facial expression, posture, gait

Speech

Affect and facial expression appropriate to

situation. Patient not observed OOB.

Speech clear.

Skin

Color, texture, hygiene, moisture

Braden score

Intactness, lesions, breakdown

Skin mostly warm and dry. Braden score-

20. Catheter insertion site found with dried

sanguineous urine around meatus. Area

cleaned thoroughly. R midline dressing

covered with Telfa cloth adhesive dressing

soaked with dried blood inferior to

incision, gauze covering changed, JP drain

intact. Midline and 2 groin incisions at top

of each leg clean, dry and well

approximated with derma bond. No other

skin lesions or breakdown

Room and equipment

IV fluids, IV access

Tube feedings

Drains, Foley

D51/2 NS + 20 mEq KCl at 125 ml/hr in 18

gauge LFA PIV. R wrist PIV medlocked.

Foley catheter. JP drain from R midline

incision drained 19 ml sanguineous fluid,

drain reactivated. (Drain later removed by

MD, incision left clean, dry and intact).

Neuro

LOC, pupils

Hand grips

Feet flexion, extension

Oriented x4. Grips, flexion, extension

strong bilaterally.

C-V: pulses Heart: rhythm, S1, S2,

extra sounds Capillary refill JVD,

bruits Edema

S1, S2 auscultated over aortic, pulmonic,

erbs point, tricuspid and mitral areas.

Pulse rate 70. Radial 3+, R dorsalis pedis

2+ . Cap refill


2/5

expansion Breath sounds clear in all areas.

GI: abdominal shape, appearance

bowel sounds x 4 tenderness last BM,

usual pattern

Abdomen round and soft. Bowel sounds x

4.Tenderness only in compromised areas.

No BM since the day before operation

(3/4/08).

G-U: voiding pattern Amount, color,

clarity, Urgency, frequency, pain onvoiding Bladder tenderness or

distention

180 ml clear amber urine drained from

Foley catheter. No pain or bladdertenderness reported. No distention.

Psy/ Soc

Family/ support systems

Lives with wife, who will be caregiver as

needed upon discharge

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and effectiveness

Pain noted at 6 on the number scale. Pain

medication administered and pain noted at

3 on same scale 30 minutes later.

Rest/ Sleep

Usual pattern/ changes since

hospitalized

Sleeping aids used

Pt reported no sleep problems other than

hospital required interruptions.

Other: specific to your patient, incl.

Dressings/ treatments

GeneralAppearance

Affect, facial expression,

posture, gait

Speech

Flat affect. Posture stupped. Gait

unsteady and weak. Speech clear.

Affect and facial expression

appropriate to situation. Posture

erect. Gait weak. Speech clear.


3/5

Skin

Color, texture, hygiene,

moisture

Braden score

Intactness, lesions,

breakdown

Skin pink, cool and dry. Braden

score- 18. Abdominal sagittal

midline well approximated

incision with packed wound at

inferior and superior ends, both

approx 1 cm in circumference and

11-12 mm in depth, no site

redness or swelling, scant

sanguiness drainage. Three

puncture wounds from

laparoscopic nephrectomy, well

approximated, covered with steri-

strips located right medial

midline, inferior and superior left

lateral abdominal area, no site

swelling or redness. No other skin

lesions or breakdown found.

Skin pink, cool and dry. Braden

score- 17. Abdominal sagittal

midline well approximated

incision with packed wound at

inferior and superior ends, both

approx 1 cm in circumference and

11-12 mm in depth, no site redness

or swelling, scant serosanguiness

drainage. Three puncture wounds

from laparoscopic nephrectomy,

well approximated, covered with

steri-strips located right medial

midline, inferior and superior left

lateral abdominal area, no site

swelling or redness. No other skin

lesions or breakdown found.

Room and

equipment

IV fluids, IV access

Tube feedings

Drains, Foley

NS at 50 ml/hr in 22 gauge LFA

IVAD, insertion date 6/1/08.Dressing clean, dry, intact and

reinforced with . No other tubes,

drains, or Foley.

22 gauge LFA S/L, insertion date

6/1/08. Dressing clean, dry intact,and reinforced with . No other

tubes, drains, or Foley.

Neuro

LOC, pupils

Hand grips

Feet flexion, extension

Oriented x4. Grips, flexion,

extension strong bilaterally.

Oriented x4. PERRL. Grips,

flexion, extension strongbilaterally.

C-V: pulses Heart: rhythm,

S1, S2, extra sounds Capillary

refill

JVD, bruits

Edema

S1, S2 auscultated over aortic,

pulmonic, erbs point, tricuspid

and mitral areas. Pulse rate 72.Radial pulse 2+, dorsalis pedis

and posterior tibial pulses 1+

bilaterally. Cap refill


4/5

Breath sounds

breath sounds clear. areas.

GI: abdominal shape,

appearance bowel sounds x 4

tenderness

last BM, usual pattern

Abdomen firm and round. Bowel

sounds x 4. General abdominal

tenderness reported. Reported

last BM was formed 5/31/08.

Abdomen firm and round. Bowel

sounds hyperactive x 4. Soft stool

at approx 10:00 after

administration of Ducolax

suppository.

G-U: voiding pattern

Amount, color, clarity,

Urgency, frequency, pain on

voiding

Bladder tenderness or

distention

230 ml clear, yellow urine. No

pain, urgency, frequency or

tenderness with voiding reported.

No bladder distention reported.

Reported voiding x 2 this morning.

No pain, urgency, frequency or

tenderness with voiding reported.

No bladder distention reported.

Psy/ Soc

Feelings or concerns r/t

hospitalization, illness.

Recent stressors, anxiety or

depression. Family/ support

systems

Pt transferred from rehab facility

and expects to go back to another

facility prior to going back home

where wife is caregiver. Wife has

arthritis and back problems, so

in-home assistance may be

needed for a period of time. Pt

concerned about pet (Beauty) and

not being able to take her on long

walks which they both enjoy. Not

being able to do this andanticipating never being able to

do this along with unrelieved pain

and lack of sleep caused pt to say

if I had a gun, I would shoot

myself.

Daughter (who is able to give some

support for pt and caregiver) and

wife are arranging placement for pt

into a rehab facility upon expected

discharge today. Pt is please that

he has been able to self ambulate

today, but has concern of repeated

evisceration.

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and

effectiveness

Pain noted at 5 on the number

scale at incision site and radiating

to right side. PRN Oxycodone

pain medication administered

with no relief within 30 minutes.

PRN acetaminophen

administered with pain decreased

to a 3 with 30 minutes. Patients

report of consistent lack of pain

relief reported to his nurse.

Pain noted at 5 on the number

scale at incision site and radiating

to right side. PRN Oxycodone pain

medication administered with pain

decrease to 3 within 30 minutes.


5/5

Rest/ Sleep

Usual pattern/ changes since

hospitalized

Sleeping aids used

Pt reported not being able to get

any sleep due to unrelieved pain.

Pt reported reduced pain and was

able to get rest during the night.

Other: specific to your

patient, incl. Dressings/

treatments

Abdominal incision site packed

with NuGauze, covered with (2)

44, left untapped, then covered

with binder. Two abdominal pads

placed underneath top edge on

binder to prevent chaffing.

Dressing changed by Dr. during

rounds this morning. Dressing

found clean and intact with scant

amount of sanguiness drainage

during assessment. Order fordressing change TID.

Abdominal incision site dressed

with approx. 4 inches NuGauze

(both superiorly and inferiorly),

covered with (2) 44, tapped, then

covered with binder. Two

abdominal pads placed underneath

top edge on binder to prevent

chaffing. Dressing changed 11:00

and found scant amt of

serosanguiness drainage on the

both pieces of NuGauze. Order fordressing change TID

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Assessment Documentation Examples