Josephine Morrow
Documentation Assignments
1. Document the findings of a focused skin assessment of Ms. Morrow, including any
findings that identify the presence of chronic venous insufficiency. Moderate edema and
hyperpigmentation of the skin from knees down to feet bilaterally. Skin intact except for
skin lesion on right lower leg. Normal skin elasticity.
2. Document any abnormal laboratory results that are associated with the presence or status
of Ms. Morrow's stasis ulcer.
3. Record the results of Ms. Morrow's Braden Scale assessment. Lab results showed the
patient has low albumin. Her levels were at 14.7 which is below the normal range of 19
to 38 mg/DL.
Braden Scale 16 High risk for developing pressure ulcer
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
Venous stais ulcer shallow, 1 inch width, pink to red in color, w/no signs of necrosis or
infection
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
Dressing intact with no s/s of discharged. Removed old dressing, inspected wound no s/s
of discharge, irrigated with normal slaine, apllied new dressing.
6. In the chart, record patient education on ways to promote venous return.
Educated patient on ways to improve venous return. Pt. should ambulate regularly,
elevate legs with pillows, and use compression stockings. The patient stated she
understood the requirements and was able to repeat the information when asked.
From vSim for Nursing | Fundamentals. © Wolters Kluwer
Documentation Assignments
1. Document the findings of a focused skin assessment of Ms. Morrow, including any
findings that identify the presence of chronic venous insufficiency. Moderate edema and
hyperpigmentation of the skin from knees down to feet bilaterally. Skin intact except for
skin lesion on right lower leg. Normal skin elasticity.
2. Document any abnormal laboratory results that are associated with the presence or status
of Ms. Morrow's stasis ulcer.
3. Record the results of Ms. Morrow's Braden Scale assessment. Lab results showed the
patient has low albumin. Her levels were at 14.7 which is below the normal range of 19
to 38 mg/DL.
Braden Scale 16 High risk for developing pressure ulcer
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
Venous stais ulcer shallow, 1 inch width, pink to red in color, w/no signs of necrosis or
infection
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
Dressing intact with no s/s of discharged. Removed old dressing, inspected wound no s/s
of discharge, irrigated with normal slaine, apllied new dressing.
6. In the chart, record patient education on ways to promote venous return.
Educated patient on ways to improve venous return. Pt. should ambulate regularly,
elevate legs with pillows, and use compression stockings. The patient stated she
understood the requirements and was able to repeat the information when asked.
From vSim for Nursing | Fundamentals. © Wolters Kluwer
