Karley Notes 4-10.docx - 232 P STUDENT NURSE SHIFT STATUS...

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232 PSTUDENT NURSE SHIFT STATUSPhysical Assessment:General: Upon arrival to patient room, patient lying in bed asleep in semi fowlers position. Patient woke to name and touch VSS. RUA DL PICC in place. Patient on contact precaution for C. Diff.Neuro: AAO x 3 to person, place, and time. Patient able to express needs and wants adequately. PERRLA, pupil size 3 mm, no visual disturbances.CV: Heart rate and rhythm regular. Rate 98 beats per minute. Cap refill <3 seconds, peripheral pulses palpable and +3. Denies chest pain. No edema present.Resp: Lung sounds bilaterally clear and equal. Respirations unlabored with a rate of 20 breaths per minute. SPO2 96% room air. Patient denies SOB. Chest tube -20 cm, serous drainage, dressing intact, no crepitus or airleak.GI: Abdomen soft, non-distended, and non-tender. Bowel sounds active in all four quadrants. Patient is passing flatus, no BM this shift. Patient is on a regular and consumed 100% of breakfast.GU: Patient is continent and voided 100 ml urine during shift. Urine is dark yellow, clear, and non-odorous.
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  • Fall '19
  • Trigraph, pulse, Josh, Amputation, Patient Room

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