Narrative Nursing Note Name: Zachery Olsen

Date: 4/12/2022 Time: 15:00 Person A – Focused Cardio

V/S BP:120/76, P:80, Temp:98.3F, SaO2: 96%, Pain-0/10
Neuro A/Ox4, Makes eye contact, hearing intact, speech clear, calm affect
Resp Lungs Clear A/P
CV S: denies chest pain, SOB, dizziness, lightheaded.
O: apical reg x5 sites, bell+ diaphragm, No JVD. Apical82
Abd BTx4, abd soft non-tender and flat
UE Grip equal strong, Radial Pulse equal strong, cap refill <3 second
LE strength equal strong, DP equal strong, Cap.Refill < 3secs, no edema, no calf tenderness
Skin W/D/P
ZROlsen (SN)

Date: 4/13/2022 Time: 14:25 Person B – Focused GI

V/S BP:131/80, P:70, Temp:98.4F, SaO2: 98%, Pain-0/10
Neuro A/Ox4, Makes eye contact, hearing intact, speech clear, calm affect
Resp Lungs Clear A/P
CV Apical: 68, Hr reg.
Abd S: no ∆’s in appetite, denies difficulty chewing/swallowing, NKI: able to pass gas
S: No stool, emesis or urine observed
O: Oral Cavity moist, Teeth clean and decay free, pharangeal opening clear,
O: BTx4, abd soft non-tender and flat
UE Grip equal strong, Radial Pulse equal strong, cap refill 1 second
LE strength equal strong, DP equal strong, Cap.Refill < 3secs, no edema, no calf tenderness
Skin W/D/P
ZROlsen (SN)

I heard we just need two focused assessments nothing with the eye/ENT?