Cv heart rate and rhythm regular tele 27 ns 80s 90s

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CV: Heart rate and rhythm regular. Tele #27, ns 80s-90s. Rate 102 beats per minute. Cap refill <3 seconds, peripheral pulses palpable and +3. Denies chest pain. Nonpitting edema to LLE and RLE.Resp: Expiratory wheeze throughout lungs. Inspiratory and expiratory sounds clear in bilateral posterior upper lobes. Bilateral posterior bases have fine rales during inspiratory and expiratory. Respirations labored with a rate of 20 breaths per minute. SPO2 96% via NC 2L. Patient denies SOB.GI: Abdomen soft, non-distended, and non-tender. Bowel sounds active in all four quadrants. No flatus present, no BM this shift. Patient is on a renal/NCS diet and consumed 100% of his breakfast. FSBS 170 at 1130, hold Novolog (see patient chart).GU: Patient is incontinent and has voided x1 during shift. Urine is yellow, clear, and non-odorous.MS: Total assist with ADL. Ambulated to bathroom with walker and standby assist, and unsteady gait. Moves all extremities with ROM 75%. LLE weakness due to wounds.Integumentary: Skin is pink, cool, and dry. IV intact/patent to LH. RLE distal surgical wound dry, intact and covered. No drainage or odor noted. RLE proximal surgical wound dry, intact and covered. No drainage or odor noted. Right great toe dry and flaky. Open to air. Left 5thtoe amputation dry, intact and covered. Wound dressings changed per RN Josh.Pain/Comfort: No complaints of pain or discomfort.Rest/Sleep: Patient rested well throughout the night.Developmental/Psychosocial/Sociocultural: Patient is cooperative and is able to follow commands. Patient takes medication with meals only.Surgical Site Assessment/ Wound Assessment: RLE distal surgical wound dry, intact and covered. No drainage or odor noted. RLE proximal surgical wound dry, intact and covered. No drainage or odor noted.Right great toe dry and flaky. Open to air. Left 5thtoe amputation dry, intact and covered. Wound dressings changed per RN Josh.Pain Assessment:Comfort/Pain: No complaints of pain or discomfort.
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Education: Patient educated on PO medications.Safety: Patient is sitting on chair. 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
  • Trigraph, pulse, Josh, Amputation, Patient Room

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