Note from Brandon Stoneman, RN at 1991-11-22 15:00

11/22/1991 1500

Diet/appetite: Lunch - 10%

0900: No IV access at present

Mental status: resting but easily aroused, pleasant, wife @ bedside

Wound/skin care: 

• Skin assessment - duoderm to L foot and heel, L elbow, sacrum incision R groin, thigh non-remarkable, duoderm to R graft site, skin warm, very dry

Activity:

• Type: bed 
• Tolerance: well 
• Repositioned: self 
• Range of motion: MAEx4
• Rest (R)/Sleep (S): R/S 0800 - 1500

Safety: 

• Sensory deficit: HOH decreased vision
• Side rails up/bed low/stationary: x4
• Call light in reach: yes 

Bladder:

• Voided/catheter: Urinal

Bowel:

• Bowel sounds: Px4 quad
• Appearance: soft, NT/ND 

Respiratory: 

• Pattern: Regular (R)/Irregular (IR)/Normal (N)/Labored (L) - R/N 
• Breath sounds: Normal (N)/Abnormal (AB) - N 
• Cough: Productive (P)/Non-productive (NP) – N/A

Cardiac:

• Telemetry #/Rhythm: #44, NSR rate 70’s
• Chest Pain: Present (P), Absent (A): denies
• Quality of Pulses: 2+ radial, 1+ R pedal, 2+ L popliteal

Signed by Brandon Stoneman, RN at 1991-11-22 15:00