Karley Notes.docx - 226 A STUDENT NURSE SHIFT STATUS Physical Assessment General Upon arrival to patient room patient lying in bed awake in semi fowlers

Karley Notes.docx - 226 A STUDENT NURSE SHIFT STATUS...

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226 ASTUDENT NURSE SHIFT STATUSPhysical Assessment:General: Upon arrival to patient room, patient lying in bed awake in semi fowlers position. VSS, afebrile. 22 gauge IV to LUA.Neuro: AAO x 3 to person, place, and time. Patient able to express needs and wants adequately. PERRLA, pupil size 3 mm.CV: Heart rate and rhythm regular. Tele #28, ns 60-70s. Tele discontinued. Rate 77 beats per minute. Caprefill <3 seconds, peripheral pulses palpable and +3. Denies chest pain. Nonpitting edema to LLE and RLE.Resp: Expiratory wheeze throughout left lung fields. Diminished breath sounds throughout right lung fields. Respirations labored with a rate of 18 breaths per minute. SPO2 99% room air. Patient denies SOB.Receiving scheduled nebulizer treatments. Productive cough with minimal viscous white sputum.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 NCS and consumed 100% of breakfast. FSBS 101 at 0730, hold Novolog and Glucotrol (see patient chart). Patient FSBS 281 at 1115, 6 units of Novolog administered per RN Gina.
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  • Fall '19
  • Trigraph, heart rate, pulse, Patient Room, Novolog

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