Professional Documents
Culture Documents
LFA S/L, insertion date 6/1/08. Dressing clean, dry intact, and reinforced with .
No other tubes, drains, or Foley.
Neuro - LOC, pupils- - Hand grips - Feet flexion, extension
Oriented x4. Grips, flexion, extension strong bilaterally.
PERRL. Grips, flexion, extension strong bilaterally.
Oriented x4.
C-V: pulses Heart: rhythm, S1, S2, extra sounds Capillary refill
JVD, bruits
Edema
S1, S2 auscultated over aortic, pulmonic, erbs point, tricuspid and mitral
areas. Pulse rate 72. Radial pulse 2+, dorsalis pedis and posterior tibial
pulses 1+ bilaterally. Cap refill <2 sec. No JVD or bruit. Non-pitting edema in
hands and feet bilaterally. S1, S2 auscultated over aortic, pulmonic, erbs
point, tricuspid and mitral areas. Pulse rate 76. Radial pulse 2+, dorsalis
pedis and posterior tibial pulses 1+ bilaterally. Cap refill <2 sec. No JVD or
bruit.
Resp: rate, rhythm, depth, effort Accessory muscle use Chest
expansion - Breath sounds
Rate 20, even, unlabored respirations. No accessory muscles used. RLL wet,
all other breath sounds clear.
Rate 20, even, unlabored respirations. No
accessory muscles used. Breath sounds clear in all areas.
GI: abdominal shape, appearance bowel sounds x 4 tenderness last BM, usual pattern
Abdomen firm and round. Bowel sounds x 4. General abdominal tenderness
reported. Reported last BM was formed 5/31/08.
Abdomen firm and round.
Bowel sounds hyperactive x 4. Soft stool at approx 10:00 after administration
of Ducolax suppository.
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain
on voiding - Bladder tenderness or distention
230 ml clear, yellow urine. No pain, urgency, frequency or tenderness with
voiding reported. No bladder distention reported. Reported voiding x 2 this
morning. No pain, urgency, frequency or tenderness with voiding reported.
No bladder distention reported.
Psy/ Soc - Feelings or concerns r/t hospitalization, illness. Recent
Pt