Nurses Notes - Pearson Education
Chapter 18
Companion Website 15
DOCUMENTATION
The following is a sample narrative documentation for health assessment of the peripheral vascular system in an 18-year-old healthy female.
Nurses Notes:
Subjective Data:
Visit for annual physical examination. No history of vascular problems, heart disease, diabetes, or obesity. No medications, no tobacco use. No pain, cramping, or swelling in extremities.
Objective Data:
Vital signs: B/P 118/66 (L), 120/70 (R) sitting. Carotids regular, no bruits. Upper extremities warm, pink, symmetrical in size, no lesions, no edema. Capillary refill < 2 sec bilaterally. Pulses regular rhythm, equal, 2 radial rate 80. Lower extremities warm, pink, symmetrical in size, even hair distribution, no lesions, no edema, no varicosities, faint superficial vessels, toenails clear and pink. Pulses 2, regular, equal. No lymphadenopathy. Homans' sign negative --bilaterally.
The following is a sample for documentation of normal findings in a flow sheet.
16 Companion Website
ASSESSMENT FORM
EXAM Peripheral Vascular System Blood Pressure
Sitting Left 118/66 Right 120/70
FINDINGS
Standing 114/64 118/68
Supine 114/60 116/66
Upper Extremity Skin
Left: Color Pink Right: Color Pink
Temperature Warm Temperature Warm
Capillary Refill
Left 2 sec
Right 2 sec
Arm Size
Left Right
Edema
Pulses Radial Ulnar Brachial
Left 0 1
2
Right 0 1
2
Rate 80 Rate 80 Rate 80
Rhythm Rhythm Rhythm
Regular Regular Regular
3
4
3
4
Amplitude 2 Amplitude 2 Amplitude 2
Lower Extremity Skin
Legs
Left: Color Pink Right: Color Pink
Temperature Warm Temperature Warm
Feet
Left: Color Pink Temperature Warm
Right: Color Pink Temperature Warm
Leg Size Edema
Legs
Left Right yes
no
Left 0 1
2
3
4
Right 0 1
2
3
4
Feet
Left 0 1
2
3
4
Right 0 1
2
3
4
Superficial Veins
Left Faint Right Faint
Lesions
Left 0 Right 0
Homans' Sign
Left
- Right
-
Toenails
Left Clear, pink Right Clear, pink
Pulses Femoral Popliteal Posterior Tibial Dorsalis Pedis
Rate 82 Rate 82 Rate 82 Rate 82
Rhythm Rhythm Rhythm Rhythm
Regular Regular Regular Regular
Amplitude 2 Amplitude 2 Amplitude 2 Amplitude 2
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