Note from Brandon Stoneman, RN at 1991-11-21 15:30

Diet/Appetite: Breakfast/Lunch 

• Assisted (A), Self (S), Feed (C)
• Amount %: 20%, 10%

Number of stools: Guaiac 

I.V. Therapy and Blood Products: 0800 No IV access 

Mental Status: alert & oriented 

Hygiene:

• Self (S), Assisted (A), Complete Bath (C)
• Oral Care
• Back Rub

Wound/Skin Care:

• Location/Dressing Change: ddi R thigh, duoderm L foot, L shin, sacral area, L elbow; ace to R partial foot amputation
• Appearance: skin w/d 

Activity:

• Type: bed/PT
• Tolerance: well 
• Distance of Ambulation: in room & PT 
• Repositioned: with help 
• Range of Motion: MAE x4 
• Rest (R), Sleep (S) from 0800 - 1500

Safety:

• Sensory Deficit: HOH poor vision

Bowel:

• Bowel Sounds: Present (P), Absent (A) x4 quad
• Appearance: soft; NT, ND

Respiratory:

• Pattern: Regular (R)/Irregular (IR)/Normal (N)/Labored (L)
• Breath Sounds: Normal (N)/Abnormal (AB)
• Cough: Productive (P)/ Non-Productive (NP)
• O₂ Therapy/Type: N/A

Cardiac:

• Telemetry # and Rhythm: Tele #44; NSR rate 70's
• Chest Pain: Present (P), Absent (A)/Action - denies 
• Quality of Pulses: 2+ radials, 1+ pedal

Signed by Brandon Stoneman, RN at 1991-11-21 15:30