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.

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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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