Assessment Documentation Examples

Assessment Thursday Friday

General Appearance
Affect, facial expression, posture, gait

Affect and facial expression appropriate to

situation. Patient not observed OOB.
Speech clear.

Speech

Skin
Color, texture, hygiene, moisture

Skin mostly warm and dry. Braden score20. Catheter insertion site found with dried
sanguineous urine around meatus. Area
cleaned thoroughly. R midline dressing
covered with Telfa cloth adhesive dressing

Braden score

soaked with dried blood inferior to

incision, gauze covering changed, JP drain

Intactness, lesions, breakdown

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

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).

Drains, Foley

Neuro

Oriented x4. Grips, flexion, extension

strong bilaterally.

LOC, pupils
Hand grips
Feet flexion, extension

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

extra sounds Capillary refill JVD,

S1, S2 auscultated over aortic, pulmonic,

erbs point, tricuspid and mitral areas.

bruits Edema

Pulse rate 70. Radial 3+, R dorsalis pedis

2+ . Cap refill <3 sec. No JVD. Or bruit. No
edema.

Resp: rate, rhythm, depth, effort

Rate 20, even, unlabored respirations. No

Accessory muscle use Chest

accessory muscles used. Breath sounds

expansion Breath sounds

clear in all areas.

GI: abdominal shape, appearance

bowel sounds x 4 tenderness last BM,

Abdomen round and soft. Bowel sounds x

4.Tenderness only in compromised areas.

usual pattern

No BM since the day before operation

(3/4/08).

G-U: voiding pattern Amount, color,

clarity, Urgency, frequency, pain on

180 ml clear amber urine drained from

Foley catheter. No pain or bladder

voiding Bladder tenderness or

distention

tenderness reported. No distention.

Psy/ Soc

Lives with wife, who will be caregiver as

needed upon discharge

Family/ support systems

Pain
Intensity (specify tool)

Pain noted at 6 on the number scale. Pain

medication administered and pain noted at
3 on same scale 30 minutes later.

Location, character
Associated signs/ symptoms
Pain interventions and effectiveness

Rest/ Sleep

Pt reported no sleep problems other than

hospital required interruptions.

Usual pattern/ changes since

hospitalized

Sleeping aids used

Other: specific to your patient, incl.
Dressings/ treatments

General
Appearance
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.

Skin

Skin pink, cool and dry. Braden

score- 18. Abdominal sagittal

Skin pink, cool and dry. Braden

score- 17. Abdominal sagittal

midline well approximated

incision with packed wound at

midline well approximated

incision with packed wound at

inferior and superior ends, both

approx 1 cm in circumference and

inferior and superior ends, both

approx 1 cm in circumference and

Braden score

11-12 mm in depth, no site

redness or swelling, scant

11-12 mm in depth, no site redness

or swelling, scant serosanguiness

Intactness, lesions,

sanguiness drainage. Three

puncture wounds from

drainage. Three puncture wounds

from laparoscopic nephrectomy,

laparoscopic nephrectomy, well

approximated, covered with steri-

well approximated, covered with

steri-strips located right medial

strips located right medial

midline, inferior and superior left

midline, inferior and superior left

lateral abdominal area, no site

lateral abdominal area, no site

swelling or redness. No other skin

swelling or redness. No other skin

lesions or breakdown found.

Color, texture, hygiene,

moisture

breakdown

lesions or breakdown found.

Room and
equipment

NS at 50 ml/hr in 22 gauge LFA

IVAD, insertion date 6/1/08.

22 gauge LFA S/L, insertion date

6/1/08. Dressing clean, dry intact,

Dressing clean, dry, intact and

reinforced with . No other tubes,

and reinforced with . No other

tubes, drains, or Foley.

IV fluids, IV access

drains, or Foley.

Tube feedings
Drains, Foley

Neuro

Oriented x4. Grips, flexion,

Oriented x4. PERRL. Grips,

extension strong bilaterally.

flexion, extension strong

bilaterally.

C-V: pulses Heart: rhythm,

S1, S2 auscultated over aortic,

S1, S2 auscultated over aortic,

S1, S2, extra sounds Capillary

refill

pulmonic, erbs point, tricuspid

and mitral areas. Pulse rate 72.

pulmonic, erbs point, tricuspid

and mitral areas. Pulse rate 76.

JVD, bruits

Radial pulse 2+, dorsalis pedis

and posterior tibial pulses 1+

Radial pulse 2+, dorsalis pedis and

posterior tibial pulses 1+

bilaterally. Cap refill <2 sec. No

JVD or bruit. Non-pitting edema

bilaterally. Cap refill <2 sec. No

JVD or bruit.

LOC, pupils
Hand grips
Feet flexion, extension

Edema

in hands and feet bilaterally.

Resp: rate, rhythm, depth,

Rate 20, even, unlabored

Rate 20, even, unlabored

effort Accessory muscle use

Chest expansion

respirations. No accessory
muscles used. RLL wet, all other

respirations. No accessory muscles

used. Breath sounds clear in all

breath sounds clear.

areas.

GI: abdominal shape,

Abdomen firm and round. Bowel

Abdomen firm and round. Bowel

appearance bowel sounds x 4

tenderness

sounds x 4. General abdominal

tenderness reported. Reported

sounds hyperactive x 4. Soft stool

at approx 10:00 after

last BM was formed 5/31/08.

administration of Ducolax
suppository.

G-U: voiding pattern

230 ml clear, yellow urine. No

Reported voiding x 2 this morning.

Amount, color, clarity,

Urgency, frequency, pain on

pain, urgency, frequency or

tenderness with voiding reported.

No pain, urgency, frequency or

tenderness with voiding reported.

voiding

No bladder distention reported.

No bladder distention reported.

Pt transferred from rehab facility

Daughter (who is able to give some

and expects to go back to another

facility prior to going back home

support for pt and caregiver) and

wife are arranging placement for pt

where wife is caregiver. Wife has

arthritis and back problems, so

into a rehab facility upon expected

discharge today. Pt is please that

in-home assistance may be

needed for a period of time. Pt

he has been able to self ambulate

today, but has concern of repeated

concerned about pet (Beauty) and

not being able to take her on long

evisceration.

Breath sounds

last BM, usual pattern

Bladder tenderness or
distention

Psy/ Soc
Feelings or concerns r/t
hospitalization, illness.
Recent stressors, anxiety or
depression. Family/ support
systems

walks which they both enjoy. Not

being able to do this and
anticipating 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.

Pain
Intensity (specify tool)

Pain noted at 5 on the number

Pain noted at 5 on the number

scale at incision site and radiating

to right side. PRN Oxycodone

scale at incision site and radiating

to right side. PRN Oxycodone pain

pain medication administered

with no relief within 30 minutes.

medication administered with pain

decrease to 3 within 30 minutes.

Location, character

PRN acetaminophen
administered with pain decreased

Associated signs/ symptoms

to a 3 with 30 minutes. Patients

report of consistent lack of pain

Pain interventions and

effectiveness

relief reported to his nurse.

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

Abdominal incision site packed

Abdominal incision site dressed

patient, incl. Dressings/

treatments

with NuGauze, covered with (2)

44, left untapped, then covered

with approx. 4 inches NuGauze

(both superiorly and inferiorly),

with binder. Two abdominal pads

placed underneath top edge on

covered with (2) 44, tapped, then

covered with binder. Two

binder to prevent chaffing.

Dressing changed by Dr. during

abdominal pads placed underneath

top edge on binder to prevent

rounds this morning. Dressing

found clean and intact with scant

chaffing. Dressing changed 11:00

and found scant amt of

amount of sanguiness drainage

during assessment. Order for

serosanguiness drainage on the

both pieces of NuGauze. Order for

dressing change TID.

dressing change TID

Rest/ Sleep
Usual pattern/ changes since
hospitalized

Sleeping aids used