Karley Burcena HawCC Student Nurse 226A STUDENT NURSE SHIFT STATUS Physical Assessment: General: Upon arrival to patient room, patient lying in bed awake in semi fowlers position. VSS. IV to RFA. Neuro: AAO x 3 to person, place, and time. Patient able to express needs and wants adequately. PERRLA, pupil size 3 mm to left eye. Right eye blindness. No visual disturbances. CV: Heart rate and rhythm regular. Rate 76 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 94% room air. Patient moved to 1 L oxygen via NC. GI: Abdomen soft, non-distended, and non-tender. Bowel sounds active in all four quadrants. Passing flatus, no BM this shift. Patient is on renal diet. GU: Patient is continent, ambulate to bathroom with one person assist. Patient voided x1 during shift. Urine is yellow, clear, and non-odorous. Patient had permacath placement. Patient tolerated procedure well, no complaints of discomfort or pain. No distress noted.
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- Fall '19
- pulse, Central venous catheter, visual disturbances, Patient Room