Answer Happy

Week 3 LAB
Documentation assignment
Cover sheet (see APA format in the
Library)
Patient information
The client is a 65 y/o male. Complaint of hip pain after
walking the dog this am.
VS: B/P 180/96, HR 92, R 18, O2 95, T 98.1
Pain level to be assessed.
You as the admitting nursing write a focused assessment (point
of pain or injury). You need to think about what is needed in your
admission (hint: comprehensive health assessment & general
survey). Name, DOB, history (what happened). You are the
nurse: what do you do first? Assessment techniques.
Expectations:
Include subjective and
objective data.
What actual or potential safety risk findings
do you assess with this client?
What are the patient’s strength and
weaknesses?
Lab documentation: use template attached,
please.
Submit to Lab assignment Documentation drop
box.
Documentation assignment
Cover sheet (see APA format in the
Library)
Patient information
Assessment:
Subjective data
Objective data
Potential risk (nursing diagnosis)
Actual risk (nursing diagnosis)
Strength
Weakness
Reference page