Name: Beatrice Barker            Pt. ID#:           0000001            Bed: 431
Admitting diagnosis: Heart Failure                 Admitting physician: Dr. Doolittle
Allergies: NKA

Mental Status
alert & oriented to person, place, time
Mood & affect:                   pleasant     tearful    
Behavior:             cooperative    
Comments:
_____________________________________________________
Pain/Comfort
pain free  
Comments:
_________________________________________________________
Head & Neck
Oral cavity:  moist             dry          :     
Sclera/conjunctiva:  clear :     
Pupils:   equal     
Pupil reaction:    R: brisk    pupil size: 4mm
L: brisk    pupil size: 4mm
Comments:
_______________________________________________________
Chest:
O2Sat:   94%        Respiratory rate: 24        Respiratory effort:   abnormal-describe: using accessory muscles
Breathe sounds:                  equal      bilateral   diminished
Abnormal:            R:            anterior  crackles  posterior crackles                upper crackles      lower crackles 
                                L:            anterior  crackles  posterior crackles                upper crackles      lower crackles 
Cough:  productive-describe sputum: white frothy
Oxygen:  NC- 4L/min
Chest tube: n/a     
Comments: O2 sat 84% on room air
__________________________________________________
Heart sounds:
Apical pulse: 98 regular                   
Comments:
_______________________________________________________
Gastrointestinal
Abdomen:          soft         nondistended       
nausea  emesis –describe: yellow, thin
Bowels sounds:    hypoactive x 4 quadrants
Comments:                
Last BM: yesterday           
Comments:
_______________________________________________________
Genitourinary
Urine:                    voids:  incontinent                              
Urine color:  color, yellow
Comments:
___________________________________________________________________________
Peripheral
Radial pulses:      equal/bilateral
R: +2
L: +2
Dorsalis pedis:    equal/bilateral
R: +2
L: +2
Posterior tibial:  equal/bilateral
R: +2
L: +2
Capillary refill:  greater than 3 seconds
Comments:       
Handgrips:           equal/bilateral
R:            weak     
L:            weak     
Movement upper extremities:         equal/bilateral
R:            weak     
L:            weak     
Movement lower extremities:         equal/bilateral
R:            weak     
L:            weak     
Comments:       
Sensation:              present/appropriate           
Comments:
________________________________________________________________________
Integument
Skin:      dry          warm     
Color:    flushed   
Turgor:                 elastic    
Nailbeds:              cyanotic                                other:    
Edema:                 generalized            sacral     pedal: +3
Comments:
___________________________________________________________
IV sites
IV start date: Today
peripheral-catheter gauge: 20          
Location:             
saline lock    right forearm
no redness, edema      occlusive dressing intact
Comments:
Isolation: N/A
Comments:      
Fall Precautions:  active
Decubitus Precautions:  n/a