NSG 122 Unit 7 basic care procedure record example

Nursing Fundamental Concepts Herzing University Free custom sample in 24 to 48h

This NSG 122 Unit 7 basic care procedure record example documents morning care on hospital day three for the same 84-year-old man: a seated wash, perineal care, mouth care and a linen change. Herzing NSG 122 asks BSN students to document care in time order with what was observed, and this sample identifies the patient and reason for care first, using the classroom format. The record runs from 0805, with hand hygiene, introduction and identification by full name and date of birth, through each part of care with times and findings, such as intact skin over the sacrum. The state at the end of care records him seated in the chair, alert and saying he feels much better, cleaner. Sources for terms and format close the record. It follows Potter's documentation guidance. About 500 words.

CourseNSG 122 Nursing Fundamental Concepts
UnitUnit 7
Paper typeBasic care procedure record
LengthAbout 760 words, 5 pages
FormatAPA 7 student paper
SchoolHerzing University
ProgramBSN
UpdatedOctober 2026

Free sample paper for NSG 122 Unit 7

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Morning Care Record, Hospital Day Three: Seated Wash, Perineal Care, Mouth Care, and Linen Change for an 84-Year-Old Man, Entry by Entry

Student Name

Department of Nursing, Herzing University

NSG 122: Nursing Fundamental Concepts

Instructor Name

February 25, 2026

What this page is doingThe title lists the care given and says the record runs entry by entry. It signals a plain chronological record, not a rationale, which is the difference this unit is testing.
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Morning Care Record, Hospital Day Three: Seated Wash, Perineal Care, Mouth Care, and Linen Change for an 84-Year-Old Man, Entry by Entry

Patient and Reason for Care

Patient identified by the classroom format: composite adult male, age 84, Bed 12, simulated medical record number 000-4471. Reason for care: morning hygiene on hospital day three; patient unable to shower safely because of a persistent fall in blood pressure on standing; requested a wash. Care given by a nursing student under the supervision of the primary nurse.

Record

0805. Hand hygiene performed on entering the room. Introduced self. Patient identified by stating his full name and date of birth, matched to the wristband. Explained the planned care; patient agreed and asked to keep his undershirt on until his back was washed.

0808. Door closed, curtain drawn, window blind lowered. Room temperature checked at 23 °C. Bed lowered, brakes on. Basin filled with warm water, tested on the inner wrist; patient said the temperature was comfortable.

0812. Patient assisted to a sitting position at the bedside, feet flat on the floor. Reported no dizziness sitting. Gait belt applied. Chair with arms placed alongside the bed.

0815. Patient washed his own face, neck, arms, and chest with a washcloth, seated, with the basin on the over-bed table. Undershirt removed after his arms were washed. Back washed and dried by the student. Skin of back and shoulders warm, dry, intact, without redness over the scapulae or spine.

0822. Assisted to stand with the gait belt and walker, then to pivot to the chair. Reported mild lightheadedness on standing, rated 2 of 10, resolving within about 30 seconds of sitting. Blood pressure not rechecked at this point; primary nurse informed of the brief dizziness at 0840.

0825. Legs and feet washed and dried, including between the toes, with the patient seated. Skin of both heels intact, without redness. Toenails thickened and yellow on both great toes.

0827. Unexpected finding: bruise on the inner left forearm, 5 cm above the intravenous site, 2.0 cm by 1.5 cm, purple with a yellow edge, flat, not tender to light touch. Intravenous site itself without redness, swelling, or leaking; infusion running. Patient said, "I didn't know that was there." Primary nurse informed at 0840 with the other findings.

0829. Sacrum and buttocks inspected while patient leaned forward on the walker: skin intact, color even, blanches with light pressure, no areas of warmth or firmness.

0830. Hand hygiene; clean gloves applied. Perineal care given with the patient standing briefly at the walker with the student holding the gait belt, then seated. Perianal skin: an area of redness about 4 cm by 3 cm on each side of the anus, moist, without broken skin or blisters. Patient reported stinging when washed, 3 of 10. Area cleansed with a pH-balanced no-rinse cleanser, patted dry, and a barrier cream applied from the unit supply as per the unit skin protocol. Gloves removed; hand hygiene.

0838. Clean gown and nonslip socks applied. Hair combed by the patient.

0840. Mouth care: patient brushed his own teeth at the over-bed table, with the student providing the brush, toothpaste, a cup of water, and an emesis basin. Tongue moist, pink, without coating. Gums pink, no bleeding. Lips dry; lip balm applied.

0845. Linen changed with the patient seated in the chair. No stool or urine on the bed linen. Soiled linen placed directly in the linen bag without shaking.

0852. Call light placed in the patient's right hand; he pressed it once to confirm he could reach it. Walker placed in reach. Urinal on the over-bed table. Water cup refilled with 200 mL; patient drank about 100 mL during care.

0855. Curtain opened at patient's request. Hand hygiene on leaving the room.

What this page is doingHand hygiene and identification are written at the moment they happened, and each observation sits in the entry that produced it. Nothing in the record explains why a step was done, which is what distinguishes it from the rationale assignment.
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State at the End of Care

Patient seated in the chair, alert, reported feeling "much better, cleaner." Dizziness resolved. Perianal redness unchanged in size from the previous day's documented measurement; no broken skin. Intake during care: 100 mL. Patient tolerated the care with one brief episode of lightheadedness on standing, reported to the primary nurse at 0840. Next planned care: assist to toilet on request; skin to be reinspected with next episode of perineal care.

Sources for Terms and Format

Documentation format follows the course fundamentals text (Potter et al., 2023). Descriptive terms for skin follow Nast et al. (2016). The perineal skin care products and their sequence follow the unit's protocol, which is based on guidance for moisture-related skin damage (Gray et al., 2012). No real patient's record was used; he is a composite.

References

Gray, M., Beeckman, D., Bliss, D. Z., Fader, M., Logan, S., Junkin, J., Selekof, J., Doughty, D., & Kurz, P. (2012). Incontinence-associated dermatitis: A comprehensive review and update. Journal of Wound, Ostomy and Continence Nursing, 39(1), 61-74. https://doi.org/10.1097/WON.0b013e31823fe246

Nast, A., Griffiths, C. E. M., Hay, R., Sterry, W., & Bolognia, J. L. (2016). The 2016 International League of Dermatological Societies' revised glossary for the description of cutaneous lesions. British Journal of Dermatology, 174(6), 1351-1358. https://doi.org/10.1111/bjd.14419

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.

Reading the NSG 122 Unit 7 instructions

Unit 7 asks you to document basic care procedures as they were performed. Expect to identify the patient and reason for care, record each step in time order with findings, describe the patient's state at the end and cite sources for format. Many versions ask how detailed the record should be and whether to include patient quotes. Check whether your section uses a specific charting format. Record what was done and observed, not what was planned. Include times, findings such as skin condition and the patient's response. Quotes can capture how the patient felt. Identification and hand hygiene should appear. Use professional terms for skin and oral findings.

Inside the NSG 122 Unit 7 example

The record opens with patient identification and the reason for care, written in the classroom format. Entries run in time order, each with a time stamp, the action and any finding. Hand hygiene and identification appear at the start. The wash entry notes skin condition by area. The perineal care entry notes skin integrity. The mouth care entry describes oral mucosa. The linen change entry notes positioning and safety. The final section records the patient's state, comfort and a quote. The record is factual and concise, the kind another nurse could read and know exactly what was done and found. Terms follow the course text. Privacy is maintained throughout with curtains and draping.

NSG 122 Unit 7 rubric: what full points look like

Herzing's rubric for a care record usually covers patient identification, time order, accuracy of findings, professional terminology, the patient's response and format. Skin and oral observations are read closely, because care is when they are most visible and most often missed. Identification points reward two identifiers. Time order criteria look for entries with times. Terminology points go to professional terms for skin and mucosa. Patient response earns credit for comfort and quotes. Format should match the course standard. Hand hygiene should be recorded at the start. Safety at the end of care, such as bed low and call light in reach, is often credited. Documentation follows the format in the Potter fundamentals text.

NSG 122 Unit 7 help before you submit

Care records in Unit 7 often slip by describing what should be done rather than what was done. Another frequent problem is missing times. Students often skip skin findings during care, which is when they are most visible. Identification is incomplete. Terms are informal, such as skin looked fine. The patient's response is not recorded. Safety steps after care, such as call light within reach, are omitted. Privacy measures during perineal care are not mentioned. Dizziness when moving to the chair, a known risk for this patient, goes unrecorded. Finally, record findings as you go, because graders reward a record that shows what the nurse observed during care rather than a list of tasks completed.

Get a NSG 122 Unit 7 example written to your instructions

Send the Unit 7 instructions and the rubric from your NSG 122 classroom, along with the documentation format your section uses. We write a custom example that runs in time order, writes identification and hygiene where they occurred, keeps observations inside their entries and closes on how the patient was left. First custom sample free, back in 24 to 48 hours.

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NSG 122 Unit 7 questions, answered

Should the record explain why each step was taken?

Usually not, unless the instructions ask for it, since the reasons belong to a different assignment in this course. A record holds what happened, in order, in the words documentation uses. If your section wants a short reflective note attached, keep it below the record rather than woven through the entries, where it breaks the sequence.

Which documentation format should I follow?

The one your classroom supplies, and send it with the instructions if you want the example to match. Formats differ across sections and settings, and an entry written in a shape your instructor does not use draws comment even when the content is right. Where nothing is specified, stay consistent and name the format you followed.

Can I write up care I gave in the skills lab?

Look at the instructions first, since some sections want exactly that and others want a constructed episode. Where you write from your own practice, keep every identifying detail of any person out of it. What was performed and signed off in the lab stays your work, and an example shows the written record rather than standing in for the performance.

Where can I find a free NSG 122 Unit 7 sample paper?

The full NSG 122 Unit 7 morning care record is on this page free of charge, time-stamped entries from hand hygiene to the end of care. A record for different care can be written on request.

How do I document morning care in nursing?

Record each step with the time, what was done and what was observed, such as skin condition, and end with the patient's state and comfort. This sample documents a seated wash, perineal care, mouth care and linen change.