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  • Zachery Olsen - Head Toes Assessment 6 - GI

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    Zack Olsen
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    Zachery Olsen was assessed twice on 3/9/2022. Vital signs were stable with a normal temperature, oxygen saturation, and pain level reported. Neurological exam showed he was alert and oriented. Lungs were clear on auscultation. Heart rate was regular. Abdomen was soft and non-tender without distension. Extremities showed strong grip, pulses, and capillary refill with no edema. Skin was warm, dry, and intact.

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    Zachery Olsen was assessed twice on 3/9/2022. Vital signs were stable with a normal temperature, oxygen saturation, and pain level reported. Neurological exam showed he was alert and oriented. Lungs were clear on auscultation. Heart rate was regular. Abdomen was soft and non-tender without distension. Extremities showed strong grip, pulses, and capillary refill with no edema. Skin was warm, dry, and intact.

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    5 views1 page

    Zachery Olsen - Head Toes Assessment 6 - GI

    Uploaded by

    Zack Olsen
    Zachery Olsen was assessed twice on 3/9/2022. Vital signs were stable with a normal temperature, oxygen saturation, and pain level reported. Neurological exam showed he was alert and oriented. Lungs were clear on auscultation. Heart rate was regular. Abdomen was soft and non-tender without distension. Extremities showed strong grip, pulses, and capillary refill with no edema. Skin was warm, dry, and intact.

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    Narrative Nursing Note Name: Zachery Olsen

    Date: 3/9/2022 Time: 14:00 Lab Partner


    V/S BP:118/76, 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 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)

    Date: 3/9/2022 Time: 19:25 Person A


    V/S BP:134/78, P:74, Temp:98.8F, SaO2: 98%, Pain-0/10
    Neuro A/Ox4, Makes eye contact, hearing intact, speech clear, calm affect
    Resp Lungs Clear A/P
    CV Apical: 74, 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)

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