Note from Chris Tadwell, RN at 1991-11-18 23:30

I.V. Therapy and Blood Products: No peripheral IV access is noted at this time 

Mental Status: A&Ox3 

Wound/Skin Care:

• Skin Assessment: Broken (B), Reddened (R), Intact (I) - duoderm to L foot & shin, ace wrap to R foot 
• Dressing Change: dressing CDI
• Appearance: skin w/d/pale 

Activity:

• Type: bed 
• Tolerance: well 
• Distance of Ambulation: N/A
• Repositioned: self 
• Range of Motion: MAE x4
• Rest (R), Sleep (S): 1800-1900: R, 2000: S, 2100: R, 2200-2300: S

Safety:

• Sensory Deficit: Blind R eye, HOH 

Bladder:

• Voided/Catheter: void 
• Appearance: yellow 

Bowel:

• Bowel Sounds: Present (P), Absent (A)
• Appearance: abd soft, NT/ND, BMs noted this PM 

Respiratory:

• Pattern: Regular (R)/Irregular (IR)/Normal (N)/Labored (L)
• Breath Sounds: Normal (N)/Abnormal (AB)
• Cough: Productive (P)/ Non-Productive (NP) - none noted 
• O₂ Therapy/Type: not in use 

Cardiac:

• Telemetry # and Rhythm: Irregular 
• Chest Pain: Present (P), Absent (A)/Action - denies 
• Quality of Pulses: 2+ radial, 1+ pedal

Signed by Chris Tadwell, RN at 1991-11-18 23:30

Note from Chris Tadwell, RN at 1991-11-18 20:30

0800: resting quietly in bed, skin w/d, respiration even and regular

0930: Pt. asks to get up for BM. On EOB few minutes prior to assisting pt. Often sitting up for approx. 10 minutes. Pt. eyes roll back. skin w/d. BP 124/60. P. 84. RR 16. shallow

0945: BP 128/64 P. 80 RR16, answers to name 

1030: accucheck 76 BP 120/66 P 80 RR 18. Dr. James called in OR. 

1200: BP 128/60 RR 16 - mouth dropping slighlty; grip equal and bilateral - MAE 

1415: BP: ly 144/64, sit 110/52, ST 80/48; EKG report given to Dr. Ruskin

1515: To xray via stretcher 

1530: Called ABG results to Dr. Ruskin and notified of pt new room # 

1700: Transferred to 4700. 

1705: Pt recieved to room 4712; A&O; expresses no c/o pain/other @ this time. family @ bedside 

2000: Pt. continues to rest in bed with family @ bedside; no change in previous assessment @ this time. 

Signed by Chris Tadwell, RN at 1991-11-18 20:30

Note from Chris Tadwell, RN at 1991-11-18 15:30

Diet/Appetite: Breakfast, Lunch

• Assisted (A), Self (S), Feed (C)
• Amount %: 95%, 80%

Number of stools: 1 

Mental Status: Oriented to self and place 

Hygiene:

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

Wound/Skin Care:

• Skin Assessment: Broken (B), Reddened (R), Intact (I)
• Simple/Extensive
• Location: All dressing intact
• Appearance: w/d 

Activity:

• Type: Chair x1 
• Tolerance: See notes 
• Distance of Ambulation: See notes 
• Immobility: Partial/Complete
• Repositioned: self and helped 
• Range of Motion: MAE 

Safety:

• Sensory Deficit: Vision (blind one eye)
• Observations: wife @ bedside 

Bladder:

• Voided/Catheter: void 
• Appearance: clear yellow 

Bowel:

• Bowel Sounds: Present (P), Absent (A)
• 1 soft stool 

Respiratory:

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

Cardiac:

• Chest Pain: Present (P), Absent (A)/Action - denies 
• Quality of Pulses:2+ radial, no edema

Signed by Chris Tadwell, RN at 1991-11-18 15:30

Note from Chris Tadwell, RN at 1991-11-18 07:30

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

Mental Status: A&Ox3 

Wound/Skin Care:

·       Skin Assessment: Broken (B), Reddened (R), Intact (I)

·       Location:L elbow, L foot, R leg, R foot 

·       Dressing Change: Duoderm, ace 

·       Appearance: w/d 

Activity:

·       Type: Bed 

·       Tolerance: well 

·       Distance of Ambulation: N/A 

·       Immobility: Partial/Complete

·       Repositioned: self and helped 

·       Range of Motion: MAE

·       Rest (R), Sleep (S): 0000-0700 R/S 

Safety:

·       Sensory Deficit: HOH

Bladder:

·       Voided/Catheter: void 

·       Appearance: light amber 

Bowel:

·       Bowel Sounds: Present (P), Absent (A)

Respiratory:

·       Pattern: Regular (R)/Irregular (IR)/Normal (N)/Labored (L)

·       Breath Sounds: Normal (N)/Abnormal (AB)

·       Cough: Productive (P)/ Non-Productive (NP) - N/A

·       O₂ Therapy/Type: N/A 

Cardiac:

·       Chest Pain: Present (P), Absent (A)/Action - denies 

·       Quality of Pulses: 2+, No edema 

Special Emotional Needs: emotional support pt.'s wife - Chaplain called for consult 

Signed by Chris Tadwell, RN at 1991-11-18 07:30