1515: Patient in bed, awake and alert. Oriented X1 to person. Disoriented to place and time. Pt. stated
“I’m in Ithaca.” “I hope its morning.” Pt. reoriented to place and time of day. Reported to primary RN
Cheryl. IV safe site on left forearm, clean, dry, and intact without S/S of infiltration or phlebitis. 16 fr.
Indwelling foley draining clear yellow urine. Skin pale, warm, and dry, hands and feet cold, blanket
provided. Pupils round, 3 mm, reactive to light. Sclera white, conjunctive pale. Nose patent. Lips dry and
pale, dentures in, mucous membranes pink and dry. Patient drank 240 ml of water. Skin turgor tenting,
explained importance of fluid. Patient stated “I will drink more.” Hand grip strength equal bilat. Anterior
LS clear in upper lobes bilat upon auscultation. Anterior lower lobes diminished bilat. Posterior LS with
rhonchi bilat. HOB increased to 45 degrees, encouraged deep breathing. Patient took 5 deep breaths.
Rationale explained on deep breathing and mobility. Pt. verbalized understanding. Reported to primary
RN Cheryl. AP 60 bpm, regular rhythm, S1 and S2 sounds noted without S3 or S4 sounds. Abdomen flat,
soft, non-distended. BS normoactive X4. Pt. denied pain or tenderness upon palpation of abd. Right knee
with eschar, 2 cm X 2 cm. Surrounding skin with erythema noted without open areas, drainage, odor, or
inflammation. Left knee with scab that is unopened approximately 1 cm X 1 cm, no inflammation,
drainage, or odor noted. Reported to primary RN Cheryl. Sacral area with erythema, no open areas noted.
Skin protectant #3 applied, pt repositioned to left side. Reported to primary RN Cheryl. Full active ROM
to upper extremities bilat. Limited passive ROM to bilat lower extremities. Homan’s sign not accurately
obtained due to pain upon touch from hip fx. Pedal and post tibial pulses +2 strength, regular rhythm. Left
lateral posterior aspect of heel with 2.5 cm X 1.5 cm with purpura and maroonish discoloration, no open
areas on heel noted. Right lateral malleolus with 2 cm of erythema with central eschar, no open areas,
drainage, or inflammation noted. Right bottom of foot with purpura and maroonish discoloration. Heels
offloaded, pt repositioned, pillows placed between bony prominences. Reported to primary RN Cheryl.
SCD’s on bilat. Lower extremities. Bed lowest position, side rails X2, call bell within reach. --LPSNCCC
1815: 16 fr. Indwelling foley catheter D/C. 8 ml of 0.9% NS aspirated from balloon. Pt tolerated well
without complaints of discomfort or pain. 250 ml of clear amber colored urine drained from foley. Pt
OOB to chair with 2 total assist. PM and oral care provided with assist. Pt in chair, personal items within
reach, call bell in reach. ------------------------------------------------------------------------------------LPSNCCC
1930: Pt in chair, C/O SOB, denied chest pain. O2 2L/min NC applied. Pt assisted X2 back to bed. O2 sat
100% 2L/min NC, Respirations 22, regular rhythm. Reported to primary RN Cheryl. Pt in bed resting,
bed lowest position, side rails X2, call bell in reach. ---------------------------------------------------LPSNCCC
2015: Pt in bed, A&O X3. IV safe site left forearm, clean, dry, and intact without infiltration or phlebitis
noted. AP 86 bpm, regular rhythm. Otherwise assessment unchanged. Foam boot applied to left foot,
SCD’s applied to bilat. Lower extremities. O2 on at 2L/min via NC. Pt denies any SOB, chest pain, or
dizziness. Pillows placed between bony prominences, pt repositioned, heels offloaded. Bed lowest
position, side rails X2, call bell within reach. Contact precautions maintained throughout shift. Reported
off to primary RN Cheryl. ----------------------------------------------------------------------------------LPSNCCC