What You Should Put In Your Nursing Assessment Documentation (part 2)

Photo courtesy of Christiana Care (Flickr.com)

In part 1 of our discussion, we have pointed out that limiting your nursing assessment with the sign or symptom would result in a poorly planned and executed care plan. Aside from the sign (1), the nurse should note the (2) onset, (3) location, (4) duration and (5) character of the sign or symptom. Let’s continue, shall we? (Later, we will also have a nursing assessment example that applies what we have discussed here.)

6.       Aggravating factors. Aside from the sign and symptom, the nurse should also look at the possible causes and risk factors that brought about the problem. If the client is experiencing stomach cramps, you could ask about things that usually cause or trigger stomach cramps. “Do you drink coffee?” “How many cups of coffee do you drink in a day?” “Do you frequently eat spicy food?” “What was the last food that you ate?”

Aside from exploring the etiology and risk factors, the nurse should include information that makes the symptoms worse in the nursing assessment documentation. For a person experiencing difficulty of breathing (DOB), you could ask the patient if he had any strenuous activity prior to the onset of DOB. Does he smoke? How many cigarettes per day?

7.       Relieving factors. Likewise, the nurse should also explore about things that lessen or alleviate the symptoms felt by the patient. In our example regarding stomach cramps, we could ask the patient regarding the medications that he takes. Does the medication relieve the symptoms? Other than medications, is there anything else that the patient does that lessens the symptom?

8.       Timing of the sign/symptom. This assessment parameter in the nursing assessment documentation, the nurse takes note of the frequency of the symptom, and which time of day do the symptoms appear. Going back to our client experiencing stomach aches, we could ask: “Is there any particular time of the day that you experience stomach cramps?” “How many times in a day do you feel these stomach cramps?” Moreover, the nurse should also note of the time interval between symptoms.

9.       Severity. This is perhaps one of the most important parameters that should be included in the nursing assessment documentation. Aside from the character of the symptom, patients are also particular with the severity of what they are experiencing. The perfect example to demonstrate the assessment of severity is pain: how painful is it? One great tip in assessing the severity of pain is by using a pain scale. On a scale of 1-10, with 10 being the highest level of pain, have the patient rate the pain using the scale. With children, the nurse can use the Wong-Baker Faces Pain Scale.

In exploring a patient’s sign or symptom, remember this acronym: OLDCARTS (onset, location, duration, character, aggravating factors, relieving factors, timing and severity). Although there are many things to explore about a symptom, this guide is already a good start for you to have substantial nursing assessment documentation. Aside from our discussion, don’t forget to always practice your assessment skills. Know your patient, and learn how to ask assessment questions properly. Moreover, keep in mind that nursing assessment is not just about knowledge and skills; you have to learn how to interact well with your clients to help identify their nursing problem and formulate the appropriate nursing care plan for the problem.