Awake alert and orientated to self, time and place. VS- T-36.

6C, P-89 (Right radial), R-17, BP125/60, O2 sat- 93% on room air, pain at 0 on a scale of 0-10. Hair sandy gray in color and clean.
Scalp intact. Ears and nose non-tender. Face symmetrical. Cooperative with clear speech. pupil
responsive bilaterally to light and 3mm in size bilateral. Sclera white. Mouth dry and clean.
Partial dental implants on the bottom and full top set of dentures. Carotid pulse strong and equal
bilaterally. Lymph nodes are non-palpable. No jugular vein distention. Lung sounds clear
bilaterally. Chest expansion symmetrical. Non-labored shallow breaths that are regular and quiet.
No cough or sputum. Pulse rhythm strong and regular bilaterally. S1S2 RRR. Denies chest pain.
No telemetry. Nail beds pink and cap refill < 3seconds. No edema. Skin pink and intact all over.
Skin turgor < 3 seconds. IV Running 0.15% Potassium chloride 5%dextrose 0.45% sodium
chloride at 125ml/hr. Located at the left antecubital and is a 20 gauge. Iv dressing clear and
intact. No inflammation present. Diet is NPO. Abdomen is flat, soft and symmetrical. Bowl sounds
are hypoactive in All quadrants but the LLQ where they are hyperactive. Pedal pulses palpable
and strong and regular bilaterally. Last BM was Sunday for Monday pt states. Bladder nonpalpable. Urine yellow with some blood from biopsy. Pt states moderate amount and that her
area I a little itchy. Provided pt with a washcloth to clean herself. Vulva had some edema (+1)
but she just a had a biopsy on it. Pt states that she has incontinence, but when I asked her how,
she said it was just some leakage. She uses sanitary pads. Wears glasses and doesnt have
hearing aids. Able to do ADLs on her own. Can use restroom by herself. Only limitation is her
right knee due to her osteoarthritis. Hand grasp are strong bilaterally. Has peripheral sensation
on both upper and lower extremities. Posture is straight and gait is steady. Full ROM and can
turn herself in bed. Asked if she needed anything and she said No, just a nap. Call light in
reach. ---------Cassidy Brooks, Student Nurse.