Assessment Documentation Examples

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, erb’s point, tricuspid and mitral areas.  Pulse rate 70. Radial 3+, R dorsalis pedis 2+ .  Cap refill ❤ sec. No JVD. Or bruit. No edema.  
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion  Breath sounds Rate 20, even, unlabored respirations.   No accessory muscles used.  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 on voiding Bladder tenderness or distention 180 ml clear amber urine drained from Foley catheter.  No pain or bladder tenderness 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    

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

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 strong bilaterally.
C-V: pulses  Heart: rhythm, S1, S2, extra sounds  Capillary refill

JVD, bruits

Edema

S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 72. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refill <2 sec.  No JVD or bruit. Non-pitting edema in hands and feet bilaterally. S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 76. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refill <2 sec.  No JVD or bruit.
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion

Breath sounds

Rate 20, even, unlabored respirations.   No accessory muscles used.  RLL wet, all other breath sounds clear. Rate 20, even, unlabored respirations.   No accessory muscles used.  Breath sounds clear in all 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 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”. 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.

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) 4×4, 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 for dressing change TID. Abdominal incision site dressed with approx. 4 inches NuGauze (both superiorly and inferiorly), covered with (2) 4×4, 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 for dressing change TID.
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About Heather Swift

Heather “Swifty” Swift has been Kicking mAss since 1998. At 28 she was diagnosed with ovarian cancer as a recently single mom with two small babies on her hip. After completing treatment with the thought that cancer was in her rear view mirror she worked, locally, as a volunteer for Ithaca Breast Cancer Alliance doing community outreach to be certain that no one faced cancer alone. In 2005, she had a secondary diagnosis of breast cancer and tested positive for the BRCA2 mutation, which only amped up her commitment to creating positive change and to becoming a strong and effective advocate for the young adult cancer community. Now, at age 42, Swifty, her partner, Brian, and her two teenage children work together locally, nationally and internationally to advocate for change. Swifty regularly meets with legislators to work towards tangible change in health care, legislation that addresses the needs of cancer patients, care-partners, and families. She works directly with clinicians, medical/nursing students, youth & college students, cancer support organizations and others to educate them about the special needs of young adults living with a cancer diagnosis. Swifty is passionate about providing support by connecting people living with cancer to resources, to other cancer survivors, and to mobilizing and training individuals and groups to find their inner advocate. Swifty currently works with a number of amazing, hand-selected organizations, which provide her with opportunities to educate, to advocate, and to change the conversation about cancer and to work to bring an end to the disease. A few include: LiveSTRONG, mAss Kickers, Imerman Angels, National Breast Cancer Coalition, Cancer Resource Center of the Finger Lakes, Dusty Showers & The Second Basemen, and Stupid Cancer. Swifty is an oncology nursing student in upstate New York, loves time with her family, paddling sports, and peanut butter. She is a Virgo, but not the really anal-retentive type. Her strange fascination with superheroes makes her popular in geek circles, but it can be endearing. Swifty will be riding a llama across Oregon in July of 2012 and really does believe we can achieve and end to cancer and in world peace. Motto: Never Give Up! Favorite quote: “Our own life has to be our message.” ― Thich Nhat Hanh

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