Moves all extremities with ROM 100 Integumentary Skin is pink cool and dry IV

Moves all extremities with rom 100 integumentary skin

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Moves all extremities with ROM 100%. Integumentary: Skin is pink, cool, and dry. IV site is asymptomatic, intact and patent. Wound site it clean, dry, intact and covered. Pain/Comfort: At 0730 patient stated she felt pain at “7/10.” Patient pain relieved with Norco 10/325 mg tablet PO PRN. At 1230 patient stated she felt a stabbing pain in lower right abdomen at “8/10.” Pain relieved with Ultram 50 mg PO PRN. Rest/Sleep: Patient rested well throughout the night. Developmental/Psychosocial/Sociocultural: Patient is cooperative and is able to follow commands. Surgical Site Assessment/ Wound Assessment: Lap sites X3, dressing CDI. No warmth, edema, erythema, or drainage. Pain Assessment: Comfort/Pain: At 0730 patient stated she felt pain at a “7/10.” Patient pain relieved with Norco 10/325 mg tablet PO PRN. At 1230 patient stated she felt a stabbing pain in lower right abdomen at a “8/10.” Pain relieved with Ultram 50 mg PO PRN. Education: Patient was educated on the importance of using IS every hour in relation to post operative care. Safety:
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Fall precautions in place. Call light within patients reach, side rails up x 2, wheels locked and bed in lowest position.
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  • Fall '19
  • pulse, Central venous catheter, visual disturbances, Patient Room

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