Date Time Nurses’ Notes
3/06/2
4
1930 Mike Donner
Labs:
Neuro A/O x4, makes eye contact, speech clear, hearing intact, calm expression***
Resp. Lungs clear A/P************************************************
B/P 124/76 Lt Arm, P-82, R-16, T-97.6 F, SaO2 98%, Pain 0/10 *********
Skin W/D/P, abrasion on R lower leg, no open wounds*********************
CV Apical 78, HR reg. *********************************************
Abd. BT x4, abd soft non-tender to light palpation, uniform, flat**************
UE Grips equal and strong, Radial Pulse equal and strong, Cap.refill <3secs.***
LE Foot strength equal and strong, Dorsal Ped. Pulse (DP) equal and strong,
Cap. Refill < 3secs, no edema, no calf tenderness (O) ******************
*********************************************Breanna Burton, SN
