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Uricula Case Studies

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Uricula Case Studies
0700 Pt in her room awake, CNA in pt room assisted pt. Pt looked tired and weak this morning.
0900 Pt went back to her room after breakfast with the assistance of CNA. On bed now lying down eyes opened. Focus assessment completed. Alert and oriented x4. Vs T 97.1, P 90, R 18, BP 155/77, O2 96 RA. Pt reported pain on her coccyx to 7 on scale of 0 to 10. Heart sounds regular and even, S1 and S2 auscultated. Lung sounds clear in all lobes, Respiratory even and non-shallow. Bowel sound present and active in all four quadrants. ABD soft and non-tender to palpate. Pt bowel movement this morning (2/11/16) liquid and diarrhea. Call light within her reach, bed in low position. Will continue to monitor
…………………………………………………………………....L.Gotora PNS2/WATC
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