Appendix 1

Systems Approach – Documentation Guidelines

SITUATION/SUMMARY:  Start notes with a quick summary of any significant events of shift, or the reason for nursing entry (eg admission, surgery, MET call, significant clinical change or treatment).

NEUROLOGICAL:

• Level of consciousness (Glasgow Coma Scale)
  • Alert and oriented to person, place, time
  • Delirious
  • Confusion
  • Lethargic
  • Stuporous (responds to painful stimuli?)
  • Comatose
• Pupil assessment – size (mm), shape, reactivity, EOMs, accommodation
• Motor movement – spontaneous, tremors, (posturing)
• Motor strength – motor scale 0-5
  • 0/5 = no movement or evidence of muscle contraction (flaccid)
  • 1/5 = no movement; some evidence of muscle contraction
  • 2/5 = movement with gravity eliminated
  • 3/5 = movement against gravity
  • 4/5 = movement against some resistance (generalised weakness)
  • 5/5 = movement against full resistance (normal)
• Sensory assessment
• Coordination assessment (if indicated)
• Cranial nerve assessment (if indicated)
• Visual deficits
• Auditory deficits
• Pain assessment
• Sedation
• Mental state/behaviour

Ask about and record response for associated signs/symptoms – headache, seizure activity, communication problems, verbalisations, affect, memory issues/problems, aphasias, numbness, paraesthesia, change in balance.

CARDIOVASCULAR:

• Heart rate (beats/min)
• Heart rhythm – regular/irregular.
• Cardiac auscultation – S1 and S2 heard? Any murmurs?
• BP (range)
• Temperature/colour/moisture of extremities
• Peripheral pulses (strength: 0, +1, +2, +3). Check all peripheral pulses bilaterally.
• Capillary refill x 4 extremities
• Oedema – generalised, dependent, pitting
• Diaphoresis
• ECG

Ask about and record response for associated signs/symptoms – chest pain, leg cramps, SOB, palpitations.

RESPIRATORY:

• Rate, rhythm, depth, work of breathing
• SpO2, oxygen use?
• Accessory muscle use, breathing through pursed lips?
• Thoracic excursion (i.e. chest expansion symmetrical?)
• Abnormal chest shape/size
• Tactile fremitus present?
• Breath sounds (presence of normal or adventitious breath sounds – describe)
• Sputum

Ask about and record response for associated signs/symptoms: orthopnoea, dyspnoea – (at rest and/or with exercise); cough (present, not present) (productive or non-productive); sputum – colour, consistency, amount, changes (increasing/ decreasing).

INTEGUMENTARY:

• Describe as dry/warm/cool/cold
• Colour (pallor, cyanosed, jaundiced, erythema)
• Turgor (sluggish, brisk)
• IV sites – type of catheter, gauge, number of lumens; location, when placed, site description, dressing (dry and intact); erythema, oedema, pain or heat at site?
• Describe abnormalities – scars, lacerations, erythema, oedema, pain, ecchymosis, abnormal hair loss, wounds [shape, size, location, depth, colour, exudate (colour, consistency, odour, amount)].
• Modified Waterlow Pressure Ulcer Risk score
• Pressure area pathology described and staged
• Hygiene requirements

Ask about and record response for associated signs/symptoms: pruritus.

GASTROINTESTINAL/METABOLIC:

• Current diet ordered (or usual diet regulations); amount currently eating (percentage)
• NGT/PEG – feeds or drainage
• Fasting or nil orally
• Dysphagia (solids, liquids, both)
• BMI, weight (stable or recent loss/gain)
• Bowel sounds – hyperactive, hypoactive, or present in all 4 quadrants
• Bowel habits – changes in colour, blood present, consistency, Bristol stool chart classification
• Abdominal palpation: masses? tenderness? guarding? soft/firm/rigid?
• Abdominal distension (present or not), girth measurements?
• BGL (if indicated)

Ask about and record response for associated signs/symptoms – nausea, vomiting (amount, colour, related to anything), diarrhoea, constipation, cramping, eructation, flatulence, haemorrhoids, usual frequency of stool. Describe consistency, colour. Any recent changes, any routines or aids used to maintain regularity.

FLUID REGULATION:

• Input for this shift/output for this shift, 24 hour intake/output, positive or negative balance?
• IV fluid – solution, rate, additives

Ask about and record associated signs/symptoms – moist mucosa, skin turgor, thirst.

GENITOURINARY:

• How is patient voiding? E.g. voiding spontaneously, with IDC, urinal, bedpan, uridome, incontinent
• Urine – describe amount, colour, clarity, odour + urinalysis (specific gravity, urine glucose/ketones, protein, blood, bilirubin, nitrates). MSU, bladder irrigations

Ask about and record associated signs/symptoms – dysuria, nocturia, polyuria, anuria, oliguria.

MUSCULOSKELETAL:

• Muscle mass, tone, symmetry of muscle size?, presence of tremor? Contractions?
• Range of motion
• Splints, protective devices in use (document times on/off)
• Prostheses
• Alignment
• Mobility/immobility, gait
• Falls risk assessment

Ask about and record response for associated signs/symptoms – pain, weakness, spasm, abnormalities – joint deformities, spinal deformities.

PSYCHOSOCIAL:

• Family, visitors, discussions
• Emotional or mental health considerations
• Acute Resuscitation Plan

RECOMMENDATIONS:

• Planned procedures
• Medical requests
• Alterations of medication
• Discharge planning (referrals, appointments, home support, medications)
• Tasks yet to be completed or that need follow up

Revised TL 2015, EW 2020, EW 2022

Adapted from St Vincent’s Hospital, Melbourne. svhm.org.au. October, 2020