Normal narrative bank — stable / at-baseline
Each shows what was assessed, the objective finding, the baseline comparison, functional or safety relevance, skilled judgment, and reinforcement — edit to the actual visit.
N1 Stable PAD, asymptomatic | Skilled peripheral vascular assessment completed. Dorsalis pedis and posterior tibial pulses 1+ bilaterally at the patient's known baseline for peripheral arterial disease, symmetric; capillary refill 3 seconds; feet cool but symmetric, skin intact without ulceration, no dependent rubor or elevation pallor of new concern. Patient denies claudication beyond the usual distance, rest pain, or new wounds. Findings stable from baseline. RN-level assessment was required to detect any decline in perfusion or new skin breakdown given peripheral arterial disease. Daily foot inspection, protective footwear, and warning signs of worsening ischemia reinforced; teach-back accurate. Continued skilled monitoring indicated. |
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N2 Chronic venous insufficiency, compression tolerated | Skilled peripheral vascular assessment completed. Bilateral 2+ pitting edema to mid-calf, symmetric and unchanged from chronic baseline; pulses 2+ and symmetric; capillary refill under 3 seconds; chronic hyperpigmentation at the medial ankles, stable; skin intact without ulceration. Compression garments donned correctly and tolerated, skin intact beneath. Patient denies new swelling, pain, or skin breakdown. Findings stable. RN-level assessment was required to distinguish stable chronic venous changes from new compromise and to evaluate compression effectiveness and skin integrity. Elevation, compression schedule, and skin monitoring reinforced; continued skilled monitoring indicated. |
N3 Healing venous ulcer, improving | Skilled peripheral vascular and wound assessment completed. Medial-malleolar venous ulcer now 1.2 cm, decreased from 1.8 cm at the prior visit, with a clean granulating base and decreased exudate; surrounding skin intact without increased warmth or erythema. Pulses 2+ and symmetric; 1+ ankle edema, improved from 2+. Compression and the ordered dressing in place and tolerated. Findings reflect ongoing healing. RN-level assessment was required to evaluate wound progression and perfusion and to ensure the ordered regimen is achieving healing. Wound care, compression, and elevation reinforced; continued skilled monitoring indicated. |
N4 Stable post-DVT on anticoagulation | Skilled peripheral vascular assessment completed in a patient with prior deep-vein thrombosis. No unilateral calf swelling, warmth, tenderness, or erythema; calf circumferences symmetric; pulses 2+ and symmetric; capillary refill under 3 seconds; skin intact. Patient denies new leg pain, swelling, dyspnea, or chest pain, and reports no bruising or unusual bleeding. Findings stable. RN-level assessment was required to screen for recurrent thrombosis and thromboembolic complications. Warning signs of recurrent DVT and pulmonary embolism reinforced; teach-back accurate. (Anticoagulation safety and INR monitoring are documented per the Anticoagulation Therapy overlay.) Continued skilled monitoring indicated. |
N5 Stable lymphedema with compression | Skilled peripheral vascular assessment completed. Bilateral lower-extremity lymphedema, non-pitting and symmetric, unchanged from baseline; pulses 2+ and symmetric; skin intact without breakdown, increased warmth, or new erythema; no new ulceration. Compression garments and the ordered regimen tolerated. Patient denies new swelling, pain, or skin changes. Findings stable. RN-level assessment was required to monitor for cellulitis and skin breakdown and to evaluate compression effectiveness. Skin care, compression adherence, and infection warning signs reinforced; continued skilled monitoring indicated. |
N6 Interval perfusion monitoring — stable | Skilled peripheral vascular assessment completed at the scheduled interval visit. Pulses 2+ and symmetric bilaterally; capillary refill under 3 seconds; extremities warm and symmetric in color; no edema; skin intact without ulceration; no unilateral calf swelling, warmth, or tenderness; no claudication or rest pain. Findings stable and consistent with baseline. RN-level assessment was required to detect any interval change in perfusion and to evaluate the prescribed vascular regimen. Symptoms warranting prompt reporting reviewed; continued skilled monitoring indicated. |