Note from Chris Tadwell, RN at 1991-11-16 23:30

0000: Denies discomfort. Looking forward to possible D/C next week. 

0804: sleeping. states he didn't sleep well last night. op site intact @ thigh. Ace wrap intact @ ankle duoderm intact L elbow (on for protection); family member @ bedside 

1000: duoderm patch to sacrum change. areas - two small stage II pressure areas (granulating tissue around edges), yellow center, staples removed from L groin incision intact

1200: bedrails pads ordered for pt. protection. skin thin, fragile, and he likes to sleep close to rail. 

1600: Pt. sleeping. Wife at bedside. Easily arousable. skin fragile. op site & duoderm to ace wrap to CDI. Good CMS < 3 seconds to each ext. 

2200: accucheck = 51, symptoms of hypoglycemia ; graham crackers + 120 cc of O2 given 

2300: accucheck = 143 x 2 

Signed by Chris Tadwell, RN at 1991-11-16 23:30

Note from Chris Tadwell, RN at 1991-11-16 23:30

Diet/Appetite: Dinner 

• Assisted (A), Self (S), Feed (C)
• Amount %: 50%

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

Mental Status: A&O to self and place 

Hygiene:

• Self (S), Assisted (A), Complete Bath (C)
• Oral Care
• Back Rub
• Remove/Reapply Elastic Stockings

Wound/Skin Care:

• Skin Assessment: Broken (B), Reddened (R), Intact (I)
• Simple/Extensive
• Location: L elbow, L foot, R leg to R foot 
• Dressing Change: Duoderm/Op site ACE CDI
• Appearance: skin w/d 

Activity: 

• Type: Up with assist
• Tolerance: Well 
• Distance of Ambulation: Pivots to chair 
• Immobility: Partial/Complete
• Repositioned: Self & with help 
• Range of Motion: MAE x4 
• Rest (R), Sleep (S): 1600 - R, 1700 - S, 1800-2100 - R, 2200-2300 - S 

Safety:

• Sensory Deficit: Glasses, HOH

Bladder:

• Voided/Catheter: voids as usual 
• Appearance: light amber 

Bowel:

• Bowel Sounds: Present (P) x 4 quads, Absent (A)
• Appearance: flat/soft 

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:

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

Signed by Chris Tadwell, RN at 1991-11-16 23:30

Note from Chris Tadwell, RN at 1991-11-16 15:30

Diet/Appetite: Breakfast, Lunch 

• Assisted (A), Self (S), Feed (C)
• Amount %: 60%, 75% 

Mental Status: A&O to self and place 

Hygiene:

• Self (S), Assisted (A), Complete Bath (C)

Wound/Skin Care:

• Skin Assessment: Broken (B), Reddened (R), Intact (I)
• Simple/Extensive
• Location: duoderm patches intact L elbow, sacrum, L foot
• Appearance: skin w/d

Activity:

• Type: chair x2 
• Tolerance: fair 
• Distance of Ambulation: stands & pivots 
• Immobility: Partial/Complete
• Repositioned: with help 
• Range of Motion: MAE

Bladder:

• Voided/Catheter: voids 

Bowel:

• Bowel Sounds: Present (P), Absent (A)
• Appearance: No BM 

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:

• Telemetry # and Rhythm:
• Chest Pain: Present (P), Absent (A)/Action
• Quality of Pulses: 2+ radial, no edema 

Signed by Chris Tadwell, RN at 1991-11-16 15:30

Note from Chris Tadwell, RN at 1991-11-16 07:30

Mental Status: A&O 

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 help 
• Range of Motion: MAE 
• Rest (R), Sleep (S): 0000 - R, 0100-0200 - S, 0300 - R 

Bladder:

• Voided/Catheter: Void

Respiratory:

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

Cardiac:

• Telemetry # and Rhythm: 
• Chest Pain: Present (P), Absent (A)/Action
• Quality of Pulses: 2+

Special Teaching Needs: Instructed pt's wife on application and purpose of duoderm - Good understanding. Discussed with wife to encourage pt. independence ASAP; Discussed importance of getting pt. O.O.B. - increase time up in chair as tolerated 

Signed by Chris Tadwell, RN at 1991-11-16 07:30