Adult Assessments

Adult Assessments

Always paint a clear picture of the patient's symptoms in your documentation. Be sure to include medical history, allergies to medication, and current medications related to the symptoms. Any nurse or provider should be able to see exactly why you landed on your chosen disposition based off your documentation.  


Breathing Difficulty  

  • Do you feel breathless?  

  • Are you short of breath at rest, when talking, with activity? 

  • Can you lie flat? 

  • What can you not do today that you normally can?  

  • Are you breathing faster or harder than normal? 

  • Do you hear any audible noises?  

  • Is there any blueness to your lips of face? 

  • Is your heart racing?  


  • Location - where does it hurt 

  • Level - mild/moderate/severe 

  • Characteristic - sharp, dull, achy, throbbing, etc. 

  • Duration - when did the pain start, how long does it last 

  • Consistency - does it come and go or is it constant 


  • Location - where is the drainage 

  • Amount - mild/moderate/severe 

  • Scant, teaspoon, gush, trickle, pooling 

  • Is it coming through or saturating the dressing? 

  • If vaginal bleeding - how many pads are you soaking - 1 to 2 an hour? 

  • Color - bright red, pinkish, cloudy, brown, yellow 

  • Consistency - thick, thin, mucous, jelly-like, stringy, tissue, clots 

  • Odor - is there a foul odor 

  • Duration - when did it start, is it constant or does it come and go 

  • If bleeding wound, have you held direct pressure constantly for 10 minutes? 

Alteration in Skin integrity (lump, bruise, laceration, abscess, etc) 

  • Location - where is the area located 

  • Size - coin size, tip of an eraser, pea, grape, marble, lemon, golf ball, etc. 

  • Pain - tender to touch, can you move normally (see above) 

  • Redness - surrounding skin, is there a red streak 

  • Swelling - mild/moderate/severe - double in size, noticeable difference, puffy 

  • Drainage - see above 

  • Color - black, white, red, bruised/discolored, blue 

  • Rash - raised, flat, blistered, peeling, itchy, any purple colored spots or dots 



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