The Nursing Life

Documentation Examples 2

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 refillJVD, 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 expansionBreath 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  tendernesslast 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 voidingBladder 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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