Nurses Note

Vital signs at 0800 T 97.5 P 64 R 16 B/P 130/80 O2 SAT 100% 2 l/min via n/c. O2 SAT 96% room air. Vital signs at 1200 T 98.2 P 70 R 16 B/P 148/82 O2 SAT 99% room air. Intake 1663 ml Output 1350 ml. Patient noted to be in severe pain at 0900 at right upper quadrant, B/P 162/86 HR 96 and a pain scale of 10/10. Patient assisted to turn and reposition however complaint of pain not reduced. Med nurse provided patient with pain medication. Some relief noted, pain scale 4/10 one hour following pain medication administration. Patient orientated to person, place and time. Able to make needs known. Pupils equal and reactive to light, size 3, sclerae white, conjunctivae pink. Mucous membranes moist. Patient has own teeth and wears glasses for all activities. Lung sounds clear bilaterally and throughout. No shortness of breath or cough noted. Heart rhythm regular and strong. Abdomen round, soft with right upper quadrant pain noted. Bowel sounds present all four quadrants with very little flatus passed. No masses noted. Last bowel movement noted four days prior. Patient refused prune juice at this time. Clear liquid diet continues. Urine clear, yellow, voiding without difficulty in urinal. Pedal pulses present bilaterally. Homans sign negative bilaterally. Teds stockings on. No edema noted. Good range of motion noted from all extremities. Skin warm, dry and intact. No redness noted over any pressure point areas. Patient ate 25% of breakfast and refused lunch. Patient reports loss of appetite. Patient noted to be lethargic/groggy when pain medication peaked. Patient can become unsteady on feet. Wife in visiting. IV fluids 0.9% NS at 150 ml/hr in left hand. No pain, redness, swelling or edema noted at the IV site. Bed in low position with call bell within reach. Will continue to monitor.