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Narrative Nursing Note Name: Zachery Olsen

Date: 1/20/2022 Time: 14:00 Lab Partner


V/S BP:120/80, P:68, Temp:98.3F, SaO2: 99%, Pain-0/10
Neuro A/Ox4, Makes eye contact, hearing intact, speech clear, calm affect
Resp Lungs Clear A/P
CV Apical: 66, Hr reg.
Abd 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)

Date: 1/25/2022 Time: 22:00 Person A


V/S BP:135/85, P:70, Temp:98.5F, SaO2: 98%, Pain-2/10
Neuro A/Ox4, Makes eye contact, hearing intact, speech clear, calm affect
Resp Lungs Clear A/P
CV Apical: 70, Hr reg.
Abd BTx4, abd soft non-tender and flat
UE Grip equal strong, Radial Pulse equal strong, cap refill < 3secs
LE strength equal strong, DP equal strong, Cap.Refill < 3secs, no edema, no calf tenderness
Skin W/D/P
ZROlsen (SN)

Date: 1/26/2022 Time: 22:00 Person B


V/S BP:124/79, P:68, Temp:98.2F, SaO2: 96%, 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 BTx4, abd soft non-tender and flat
UE Grip equal strong, Radial Pulse equal strong, cap refill < 3secs
LE strength equal strong, DP equal strong, Cap.Refill < 3secs, no edema, no calf tenderness
Skin W/D/P
ZROlsen (SN)

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