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?
Pain
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
Drainage/Discharge
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
