BACHELOR OF SCIENCE IN NURSING:

HEALTH ASSESSMENT
LABORATORY MODULE LABORATORY UNIT WEEK
3 3 15
DOCUMENTATION OF FINDINGS

✓ Read course and laboratory unit objectives

✓ Read study guide prior to class attendance
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:

 Understand the importance of documentation in the nursing process

 Properly document all findings noted during physical examination

Affective

 Practice effective listening during class discussion

 Inquire on topics that are not completely understood
 Share opinions on the subject matter that can enhance class discussion
Psychomotor

 Follow class rules and netiquettes

 Participate during class discussion

Health Assessment in Nursing by: J. Weber and J. Kelley Fifth Edition

Documentation of assessment data is another crucial part of the first step in the nursing
process. Health care institutions have developed assessment and documentation policies and
procedures that provide not only the criteria for documenting but also assistance in completing
the forms The categories of information on the forms are designed to ensure that the nurse
gathers pertinent information needed to meet the standards and guidelines of the specific
institutions mentioned previously and to develop a plan of care for the client.

Purpose of Documentation

The primary reason for documentation of assessment data is to promote effective

communication among multidisciplinary health team members to facilitate safe and efficient
client care. Documented assessment data provides the health care team with a data base that
becomes the foundation for care of the client. It helps to identify health problems, formulate
nursing diagnosis and plan immediate and ongoing interventions.
Case Study:

Mrs. Gutierrez, a 52 year-old female, was born in Mexico City and moved to Los Angeles when
she was 20 years old. She has been a homemaker all her adult life. Her daughter has dropped
her off at the clinic while she runs some errands. She lives with her husband and 3 daughters
(ages 12,14 and 17). She has 2 older sons who are married and live in Mexico. She shares a
cell phone and car with her oldest daughter. She completed high school in Mexico. Mrs.
Gutierrez’s family does not have private health insurance. Mrs. Gutierrez states that she has
come to the clinic because her doctor told her she needs diabetic teaching however, her
concern is “ I cannot eat or sleep and I just want to be able to eat and sleep again,
Mrs. Gutierrez’s symptoms of loss of appetite and inability to sleep were further explored using
COLDSPA.

Example of Documentation of Assessment findings on a narrative progress note.

(Subjective)

COLDSPA Client’s Response for Insomnia and Anorexia

Character I only sleep for 4 to 5 hours a night. Once I fall asleep
about 10:00 PM, I wake up about 2:00 am or 3:00 am,
and can’t go back to sleep. I don’t take naps during
the day. I eat cereal in the morning but am not able to
eat much the rest of the day. I eat less than one half of
what I used to eat. I only eat a bite of a tamale and
maybe a bite or 2 of beans or rice
Onset 2 months ago right after my husband was in a car
wreck
Location Nonapplicable
Duration 2 months
Severity I am so tired in the daytime that I have let my
housework pile up. Sometimes I just lay in bed but I do
not sleep. I know I should eating but I do not feel
hungry and food is not appetizing to me
Pattern (What makes it better or I have tried taking Excedrin but it makes me feel
worst) drowsy all day. I only drink a cup of coffee in the
morning and stopped drinking tea in the afternoon.
 Associated Factors My clothes no longer fit and are very loose. I worry a
lot as to how we will pay our bills now that my
husband has lost his job and we do not have health
insurance.

Mrs. Gutierrez’s has little knowledge of her family history as she was abandoned by her
parents as an infant and later adopted.

The review of systems for Mrs. Gutierrez is as follows:

 Skin, hair and nails: No report of problems with skin, hair or nails
 Head and Neck: Denies headaches, swelling, stiffness of neck, difficulty swallowing,
sore throat, enlarged lymph nodes.
 Eyes: Reports that she wears glasses for reading. Denies eye infection and eye pain
 Ears: Denies hearing loss, ringing or buzzing, drainage from ears, dizziness, exposure
to loud noises
 Mouth, throat, nose and sinuses: Client reports missing upper molars. Denies gum
bleeding or dental problems, denies sore throats, mouth lesions, hoarseness, rhinorrhea
and nasal obstruction, nose bleeding and snoring
 Thorax and lungs: Denies difficulty breathing wheezing, pain, shortness of breath
during routine activity, orthopnea, hemoptysis and respiratory infections.
 Breast and regional lymphatics- Denies lumps or discharge from nipples, dimpling, or
changes in breast size. Denies swollen or tender lymph nodes
 Heart and neck vessels: Client reports last blood pressure was 130/84. Denies chest
pain or pressure, palpations
 Peripheral vascular: Denies edema of legs or feet, pain, cramping, lesions on legs,
color texture, changes of leg and feet
 Abdomen- Describes lack of appetite (please see 24 hour diet recall) denies difficulty
swallowing, nausea, vomiting, gas, jaundice hernia
 Musculoskeletal: Denies erythema, pain, or stiffness of joints, denies weakness.
Reports ability to perform activities of daily living without difficulty
 Neurologic- See COLDSPA. Denies feelings of anger or suicidal thoughts. Denies
concussions, headaches, loss of strength or sensation, lack of coordination and
difficulty speaking.
 Female Genitalia- Denies sexual problems and history of STI. Menarche age 13,
Menopause at 51. Denies pelvic pain, use of oral contraceptives and use of hormone
replacement therapy
 Anus and rectum- Reports having a daily bowel movement of formed brown stool.
Denies pain with defecation, hemorrhoids, blood in stool, constipation and diarrhea.
24 hour dietary recall:

Breakfast: Small (4 oz) bowl of oatmeal with milk and sugar.

Lunch: Plain tortilla with a glass of milk
Supper: Few bites of chicken and rice, water. Client does not typically eat at restaurants.

Lifestyle and Health Practices Profile:

Mrs. Gutierrez reports that she gets up at 6:00 AM every day, does laundry and housework,
and begins to prepare meals for the day. She enjoys working outside but has not been able to
do so as much as she did since her husband’s accident. Bedtime is usually after news at 10:30
PM. Does not drink alcohol and used to drink 3 to 4 cups of coffee a day but now stop to in
order to help her sleep. Denies use of tobacco and recreational drugs. Report frequent feeling
of loneliness with her siblings and parents living far away in Mexico. “I worry a lot since my
husband’s accident and I can’t work”
Client live in a 3 bedroom home. States that there are often neighbor fights outside, but they
were never involved. Feels fairly safe but worries about the neighbor sometimes.

Example of Documentation of Assessment findings on a narrative progress note.

(Objective)

The nurse does a focused assessment on Mrs. Gutierrez focusing on her diabetes, anorexia,
and insomnia. Her physical assessment findings follow:

General Survey

Ht: 5 foot 1 inches; Wt 127 lb; Pulse 68, Resp; 18, BP 132/76 Temp; 36.5. Client alert and
cooperative. Sitting comfortably on table with arms at sides. Dress is neat and clean. Walks
steadily, with posture erect.
Mental Status Examination: Pleasant and friendly. Appropriately dressed for weather with
matching colors and patterns. Clothes neat and clean. Facial expressions symmetric and
correlate with mood and topic discussed. Speech clear and appropriate. Tearful as she
discusses her husband and his accident. Carefully chooses words to convey feelings and
ideas. Oriented to time and date, person, place and events.

 Skin, hair, nails

Skin- Light brown, warm and dry to touch. Skin fold returns to place after 1 second
when lifter over clavicle. No evidence of vascular or purpuric lesions
Hair- Straight, clean, black with white and gray streaks, and thick supple in texture. No
scalp lesions or flaking
Nails- Fingernails short in length and thickness, clear. No clubbing or Beau’s lines
 Head and Neck- Head symmetrically rounded, neck non tender with full ROM. Neck
symmetrically without masses, scars, pulsations. Lymph nodes non palpable. Trachea
in midline. Thyroid non palpable.
 Eyes- Eyes 2 cm apart without protrusion. Eyebrows thick with equal distribution. Lids
light brown without ptosis, edema, or lesions and freely closeable bilaterally. Lacrimal
apparatus non edematous. Sclera white without increased vascularity or lesions noted.
Palpebral and bulbar conjunctiva slightly reddened without lesions noted. Iris uniformly
brown. PERRLA, EOMs intact bilaterally.
 Ears: Auricles without deformity, lumps, or lesions. Auricles and mastoid process
nontender. Bilateral auditory canals clear. Tympanic membranes pearly gray bilaterally
with visible landmarks, hearing intact with whisper test bilaterally
 Mouth, Throat, Nose and Sinuses- Lips moist, no lesions or ulcerations. Buccal
mucosa pink and moist, no lesions or ulcerations. Buccal mucosa pink and moist with
patchy areas of dark pigment on ventral surface of tongue, gums and floor mouth. No
ulcers or nodules. Gums pink and moist without ulcerations and inflammation, bleedings
or discoloration. Hard and soft palates smooth without lesions or masses. Tongue
midline when protrude, no lesions or masses. No lesions, discolorations or ulcerations
on floor mouth, oral mucosa or gums. Uvula in midline and elevates on phonation.
External structure of nose without deformity, asymmetry, or inflammation. Nares patent.
Turbinates and middle meatus pale pink, without swelling, exudate, lesions or bleeding.
Nasal septum midline without bleeding, perforation or deviation. Frontal and maxillary
sinuses non tender
 Thorax and Lungs- Skin light brown without scars, pulsations or lesions. No hair noted.
Thorax expands evenly bilaterally without retractions or bulging. Respirations even,
unlabored and regular. No tenderness, crepitus or masses. Tactile fremitus equal and
symmetric bilaterally. Vesicular breath sounds heard throughout. No crackles, wheezes
or friction rubs.
 Heart and Neck Vessels- No pulsation visible. No heaves, lifts, or vibrations. Apical
impulse: 5th ICS to LMCL. Clear, brief heart sounds throughout. S1, S2 present. No S3,
S4, gallops, murmurs, or rubs.
 Abdomen- Abdomen rounded, symmetric without masses, lesions pulsations or
peristalsis noted. Abdomen free of hair, bruising and increased vasculature. Umbilicus
in midline, without herniation, swelling or discoloration Bowel sounds low pitched and
gurgling at 16/min x 4 quads. Aortic, renal and iliac arteries auscultated without bruit. No
venous hums or friction rubs auscultated without over liver or spleen. Tympany
percussed throughout. No tenderness or masses noted with light and deep palpation.
Liver and spleen nonpalpable.
 Peripheral Vascular- upper extremities; equal in size and symmetry bilaterally; light
brown; warm and dry to touch without edema, bruising or lesions. Radial Pulse= in 2+
bilaterally. Brachial pulses equal and 2+ bilaterally. Lower extremities; Legs symmetric.
Skin intact, light brown, warm and dry to touch without edema, bruising lesions or
increased vascularity. Femoral pulses 2+ and equal without bruits. Dorsalis pedal and
posterior tibial pulses 1+ and equal. No edema palpable.
 Musculoskeletal- Posture erect. Gait steady, smooth and coordinated with even base,
Full ROM of cervical and lumbar spine. Full ROM of upper and lower extremities.
Strength 5/5 of upper and lower extremities.
 Neurologic
Cranial Nerve Exam: Cranial nerves II to XII grossly intact
Motor and cerebellar exam: Muscle tone firm at rest, abdominal muscles slightly
relaxed. Muscle size adequate for age. No fasciculation or involuntary movements
noted.
Sensory Status Examination: Superficial light and deep touch sensation intact on ars,
hands, fingers, legs, feet and toes and fingers intact bilaterally. Stereogosis and
graphestesia intact

1. Perform an interview and physical assessment to an adult patient 20 to 50 years of age,

male or female.
2. Document your findings using the narrative progress note documentation as your guide
3. Attached to your nursing documentation are pictures or video clips of you conducting
the interview and health assessment provided that a consent was given by the patient