Gotora Pns2/Watc Case Study
0700 Pt in her room awake getting ready for breakfast. Pt state had a good sleep. No sign of discomfort at this time. Will continue to monitor…………L.Gotora PNS2/WATC
0830 Focus assessment. Alert and oriented x 4 and follow commands. VS T 96.7, P 76, R 18, BP 129/67, O2 Sat 94 RA. Pt denied pain at this time. Pain 0 on a scale of 0 to 10 Heart sounds normal, regular and even. S1 and S2 auscultated. Lung sounds normal and clear in all lobes. Non labored and non-shallow. Bowel sounds active and present in all four quadrants. ABD soft, non-tender to palpate. Pt denied ABD pain and constipation. Pt stated last bowel movement two days ago (2/23). Call light with in her reach, all necessary items close by pt………………………..L.Gotora PNS2/WATC
0930 Dressing
0830 Focus assessment. Alert and oriented x 4 and follow commands. VS T 96.7, P 76, R 18, BP 129/67, O2 Sat 94 RA. Pt denied pain at this time. Pain 0 on a scale of 0 to 10 Heart sounds normal, regular and even. S1 and S2 auscultated. Lung sounds normal and clear in all lobes. Non labored and non-shallow. Bowel sounds active and present in all four quadrants. ABD soft, non-tender to palpate. Pt denied ABD pain and constipation. Pt stated last bowel movement two days ago (2/23). Call light with in her reach, all necessary items close by pt………………………..L.Gotora PNS2/WATC
0930 Dressing