Professional Documents
Culture Documents
General Appearance
Affect, facial expression, posture, gait
Speech
Skin
Color, texture, hygiene, moisture
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
Braden score
Drains, Foley
Neuro
LOC, pupils
Hand grips
Feet flexion, extension
bruits Edema
usual pattern
Psy/ Soc
Pain
Intensity (specify tool)
Location, character
Associated signs/ symptoms
Pain interventions and effectiveness
Rest/ Sleep
General
Appearance
Affect, facial expression,
posture, gait
Speech
Skin
Braden score
Intactness, lesions,
breakdown
Room and
equipment
IV fluids, IV access
drains, or Foley.
Tube feedings
Drains, Foley
Neuro
JVD, bruits
LOC, pupils
Hand grips
Feet flexion, extension
Edema
respirations. No accessory
muscles used. RLL wet, all other
areas.
administration of Ducolax
suppository.
voiding
evisceration.
Breath sounds
Bladder tenderness or
distention
Psy/ Soc
Feelings or concerns r/t
hospitalization, illness.
Recent stressors, anxiety or
depression. Family/ support
systems
Pain
Intensity (specify tool)
Location, character
PRN acetaminophen
administered with pain decreased
Rest/ Sleep
Usual pattern/ changes since
hospitalized