NNN:
0745 Report received from Primary RN. IV site L antecubital, dressing clean, dry, intact. IV infusing LR @ 75ml/hr,
site clean, dry, patent c no signs of phlebitis or infiltration. C/O pain 8/10 on pain scale in lower back. Reported to
Primary RN, administered oxycodone @ 0820. A&O x4 to person, place, DOB, time. Resting in bed, awakens to
name. Calm, behavior appropriate to situation, speech articulate. T 96.6F P 56 reg R 20 easy BP 137/56 R
arm O2 98% RA Glucose 80. HEENT: Face symmetrical c calm expression, facial bones symmetrical and
proportional to size of head. L/R Eye PERRL, sclera white, conjunctiva pink/clear. Ears symmetrical, clean, dry.
Septum midline, nares symmetrical/patent, sinuses non-tender, no nasal discharge present. Breath s odor,
lips/tongue smooth, pink, moist. Gingiva pink/moist, teeth intact, clean. Trachea midline, thyroid smooth, soft,
moves freely with swallow. Lungs: LS clear upper bilaterally A&P, RLL/LLL fine crackles. BS unlabored. Cardiac: AP
59 reg, no JVD present, cap refill <3 all extremities, radial pulses equal/present+2, pedal/post tibial pulses +2
bilaterally, nail beds pink. Telemetry 58 c LBBB, no signs of edema. Abdomen: Abd round, soft, non-distended,
non-tender. Umbilical midline. BS present, active x4. LBM today. Skin is expected color for race; smooth, soft,
warm, dry, non-tenting, and intact. Nails are clean, pink, smooth. Small, blanchable, erythematic rash to sacrum,
intact. Applied aloe vesta #3 to sacrum. Hand grips equal/strong, AROM all extremities. Repositioned c patient
assist. Incontinent x1, mod amt of clear yellow urine. Cleaned with soap and water to peri area, applied #3 barrier
cream to sacral area, applied depends. Patient resting comfortably in bed. Call bell in reach, bed in lowest position.
0900 OOB to chair with 1 assist and wheeled walker. Ate 75% of breakfast- pureed oatmeal, PO fluid intake
120cc. Call bell in reach.
1000 Bed bath with patient assist. Oral care independently. Applied aloe vesta #2 on all extremities and back. No
c/o pain. Applied TEDS to bilat lower extremities. Sitting in chair, reading newspaper. Call bell in reach.
1100 BTB with 1 assist, and wheeled walker. No c/o pain. Void x1 of mod amount clear yellow urine.
1200 T 97.1F P 57 reg R 20 easy BP 132/76 R arm O2 96% RA BG 104. A&O x3 to person, place, time. Calm
pleasant, behavior appropriate to situation, no acute distress noted. Pain 6/10 in lower back with movement.
Repositioned patient to L side with pillow under back. Patient resting comfortably in bed. Call bell in reach. Bed in
lowest position. Reported off to Primary RN…………………………………………………………………………Amelia O’Bryan, SN CCC