Patient #1:

(not all of note)

1600: Resting in bed with eyes open. Responds to verbal stimuli. Alert and
oriented to person, place and time. HOH. Clear speech. VS: 97.5 F. AP 70,
reg. RR 16, easy. BP 142/78. O2 98% on RA. LS clear and diminished bilateral
lower lobes. Denies any SOB. BS + x4, normal. Abd soft, flat, on-tender.
Negative homans sign. PP present bilaterally, 2+. No edema to UE or LE.
Denies any pain. Bed in lowest position with call bell within reach.
1640: Ambulated from bathroom back to bed with ww, contact guard, and
steady gait. Denies dizziness or SOB.
1700: Incentive spirometer teaching. Demonstrates return. Needs
reinforcement. Completed 10x reaching 1500mL.
Patient #2:
(not all of note- pt post op from lap chole)

1600: Pt resting in bed with eyes open. Alert and oriented to person place
and time. VS: 97.9F. AP 66, reg. RR 18, easy. BP 124/70. O2 sat 98% on RA.
Denies any SOB. LS clear bilaterally throughout. BS + x4. normal. Abdomen
round, semi-firm, guards with touch. Trochar site at umbilicus, at 0900 and at
0700, glued with no drainage noted. Radial and PP 2+. Negative homans. No
edema to BLE. IV site left hand, no signs of phlebitis or infiltration. Skin
warm, dry and pink. Cap refil <3 secs, brisk. Family currently visiting in room.
Call bell within reach.
1700: Ambulated in hallway 500' with steady gait, denies any dizziness or
SOB. States passing flatulence without any issues. Sitting in chair besides
bed with no s/s of distress noted. Call bell within reach.