Head to toe assessment narrative PDF

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08/11/2021 1345

A&O x 4, Temp 98.0F orally, HR 97bpm, RR 16 Non labored and Regular, O2 Sat 99%, B/P 118/72 mm Hg, Denies any pain, PERRLA, Pipul 4mm bilaterally. Responds appropriately to verbal stimuli, is Abulatory, gait steady with one person stand-by. Skin clean, dry, no tenting, turgor less than 3 seconds, color appropriate for ethnicity. Hair clean, dry, no lesions, face symmetrical, no abnormalities noted. All peripheral pulses, strong, 2+, and equal bilaterally, Mucous membranes intact, respirations, even, unlabored, and clear to auscultation throughout lung fields, room air, Apical pulse regular rate and rhythm, s1,s2 noted 76bpm. Abdomen soft, not distended, no tenderness, with normoactive bowel sounds in all four quadrants. Pink nail beds, capillary refill less than 2 secs. Moves all extremities, equal strength in hands and feet bilaterally, normal urine and bowel movements, no skin breakdown noted. Bed rails up x2, call light in hand, bed in lowest position. Regular diet with no restrictions. Instructed to call with any request or needs. Will continue to monitor. C. Marley SPN...