Karley Notes 04-04.docx - 225A STUDENT NURSE SHIFT STATUS Physical Assessment General Upon arrival to patient room patient lying in bed awake in high

Karley Notes 04-04.docx - 225A STUDENT NURSE SHIFT STATUS...

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225A STUDENT NURSE SHIFT STATUS Physical Assessment: General: Upon arrival to patient room, patient lying in bed awake in high fowlers position. VSS. 18 gauge IV to RA. 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 84 beats per minute. Cap refill <3 seconds, peripheral pulses palpable and +3. Denies chest pain. No edema noted. Resp: Lung sounds bilaterally clear and equal. Respirations unlabored with a rate of 20 breaths per minute. SPO2 98% on room air. Patient denies SOB. Patient is able to use IS at 1500 for 5 tries every hour. GI: Abdomen soft, distended, and tender. Bowel sounds active in all four quadrants. No flatus, no BM this shift. Patient is on a clear liquid diet. Patient consumed 75% of her breakfast. Patient will advance to full liquid diet for lunch. GU: Patient is continent and voided 650 ml of urine this shift. Urine is yellow, clear, and non-odorous. MS: Able to perform ADLs with minimal assist. Ambulated to bathroom with standby assist, steady gait.
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  • Fall '19
  • pulse, Central venous catheter, visual disturbances, Patient Room

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