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 score20. 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 <3 sec. No JVD. Or bruit. No edema.

Resp: rate, rhythm, depth, effort Accessory muscle use Chest

Rate 20, even, unlabored respirations. No accessory muscles used. Breath sounds

expansion Breath sounds GI: abdominal shape, appearance bowel sounds x 4 tenderness last BM, usual pattern

clear in all areas. Abdomen round and soft. Bowel sounds x 4.Tenderness only in compromised areas. No BM since the day before operation (3/4/08). 180 ml clear amber urine drained from Foley catheter. No pain or bladder tenderness reported. No distention.

G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on voiding Bladder tenderness or 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

Pt reported no sleep problems other than hospital required interruptions.

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
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 steristrips 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, erbs 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. Rate 20, even, unlabored respirations. No accessory muscles used. RLL wet, all other

S1, S2 auscultated over aortic, pulmonic, erbs 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

Rate 20, even, unlabored respirations. No accessory muscles used. Breath sounds clear in all

breath sounds clear. Breath sounds

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

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.

Sleeping aids used

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 for dressing 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 for dressing change TID