(4) Assessment of the nails provides information about the patient's life-style,
self-esteem, and level of self-care as well as health status. Inspect the nails for
cleanliness, length, color, consistency, smoothness, symmetry, and for jagged or bitten
edges.
(5) Note any alterations in skin integrity such as scars, rashes, sores, lesions,
bruises, and discoloration. If the patient has a dressing, note the type, location, any
drainage, and the amount and character of the drainage.
6-8.
GUIDELINES FOR DOCUMENTATION
a. The nursing history and assessment should be completed for each patient
within 24 hours of admission. Documentation of the physical assessment should be done
in an organized fashion according to systems. Information should be thorough and flow
logically from one consideration to the next. Follow general charting rules using correct
medical terminology, spelling, grammar, punctuation, and authorized abbreviations. Use
the proper format and write neat and legibly. Depending on ward policy, the initial physical
assessment is recorded on DA Form 3888, Medical Record - Nursing History and
Assessment (see figure 6-10), DA Form 3888-1, and/or SF 510, Medical Record--Nursing
Notes (see figure 6-11).
b. DA Form 3888 (see figure 6-10) documents a baseline nursing history and
assessment on each patient. If completed at the time of admission, it may serve as the
admission-nursing note. If DA Form 3888 is completed at admission, an admission note is
not needed on SF 510. Make an entry on SF 510 to refer to the DA Form 3888 for the
admission note. Data entered on this form represents baseline health status information
used by the nurse to plan care. (See DA Form 3888 on the following pages.)
c. The nursing assessment is reviewed and revised as additional data are
collected and patient needs change. Updated nursing assessment should be documented
on the SF 510. Several methods and personnel may collect patient date from which a
plan of care is developed. Regardless of what data is collected, and by whom, the
professional nurse is ultimately responsible for the validity and reliability of the collected
data.
6-9.
CLOSING
As you learn the techniques of performing a comprehensive patient assessment,
list these techniques in the order in which they are performed. Organize the assessment
in a way that limits the number of times the patient must change positions, and the number
of times you must change your own position. Once you have developed an organized and
systematic approach and performed the assessment a number of times, you will be able to
gather both subjective and objective information quickly and effectively. This approach will
provide you with the information you need to develop your nursing diagnoses and care
plans.
MD0906
6-21