The Nursing Life

Documentation Examples

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
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