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Vsim Josephine Morrow - Documentation Assignments
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Vsim Josephine Morrow - Documentation Assignments
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Vsim Josephine Morrow - Documentation AssignmentsJosephine 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.
Skin is dry and intact, with the exception of 1-inch ulcer present on right medial malleolus that is
covered with hydrocolloid dressing. Color is normal for race with the exception of bilateral
hyperpigmentation distal to patella with +2 edema. Normal skin elasticity with no signs of sweating.
2. Document any abnormal laboratory results that are associated with the presence or status of Ms.
Morrow's stasis ulcer.
Albumin levels 3.4 g/dL (BNL of 3.5-5 g/dL); prealbumin levels 14.7 mg/dL (BNL of 19-38 mg/dL).
Both of these low levels are indicative of elevated inflammation due to a wound as well as an indication
of poor nutritional status. Bicarbonate 28 mEq/L (ANL 22-26 mEq/L) are indicative of poor bodily gas
exchange or possible dehydration, both of which can contribute to the presence of a venous stasis ulcer.
3. Record the results of Ms. Morrow's Braden Scale assessment.
Braden Scale assessment is 16. This score puts Ms. Morrow at risk for for skin breakdown and provides
a baseline for comparison of future assessments. Skin is currently intact, with the exception of a venous
stasis ulcer on right medial malleolus.
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
Venous stasis ulcer on right medial malleolus is “shallow, 1-inch in width, and looks mostly pink to red,
with no signs of necrosis or infection.”
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
Visual assessment of initial dressing: clean, dry and intact. Removed dressing to visually assess ulcer:
Shallow, 1-inch in width, and looks mostly pink to red, with no signs of necrosis or infection. Irrigated
wound with N/S. Covered wound with new dressing.
6. In the chart, record patient education on ways to promote venous return.
Patient education on ways to promote venous return included promotion of frequent ambulation and to
avoid staying in one position for a prolonged amount of time; elevation of lower legs; wiggling of feet
and legs while in bed or in a chair. Also recommended use of compression stockings due to history of
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