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  • Zachery Olsen - Head Toes Assessment 3 - Cardiac

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    Zack Olsen
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    Zachery Olsen was seen on 2/4/2022 and 2/8/2022 for lab partner visits. On both dates, his vital signs were stable with normal temperature, oxygen saturation, and no reported pain. His physical exams showed clear lungs, normal heart exam, soft non-tender abdomen, strong grip and pulses in upper and lower extremities without edema or tenderness. His neurological exam was normal on both dates.

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    Zachery Olsen was seen on 2/4/2022 and 2/8/2022 for lab partner visits. On both dates, his vital signs were stable with normal temperature, oxygen saturation, and no reported pain. His physical exams showed clear lungs, normal heart exam, soft non-tender abdomen, strong grip and pulses in upper and lower extremities without edema or tenderness. His neurological exam was normal on both dates.

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    3 views1 page

    Zachery Olsen - Head Toes Assessment 3 - Cardiac

    Uploaded by

    Zack Olsen
    Zachery Olsen was seen on 2/4/2022 and 2/8/2022 for lab partner visits. On both dates, his vital signs were stable with normal temperature, oxygen saturation, and no reported pain. His physical exams showed clear lungs, normal heart exam, soft non-tender abdomen, strong grip and pulses in upper and lower extremities without edema or tenderness. His neurological exam was normal on both dates.

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    © All Rights Reserved
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    Narrative Nursing Note Name: Zachery Olsen

    Date: 2/4/2022 Time: 14:00 Lab Partner


    V/S BP:124/84, P:68, Temp:98.3F, SaO2: 98%, 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. Apical68
    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: 2/8/2022 Time: 13:00 Person A


    V/S BP:120/80, P:66, 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 S: denies chest pain, SOB, dizziness, lightheaded.
    O: apical reg x5 sites, bell+ diaphragm, No JVD. Apical70
    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)

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