Name: Finnegan O’Moore      Pt. ID#: 0000003         Bed: 486
Admitting diagnosis: right total knee replacement     Admitting physician: Dr. Doolittle
Allergies: NKA
Today on admission:

Mental Status
alert & oriented to person, place, time
Mood & affect:                   pleasant    
Behavior:             cooperative    
Comments:
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Pain/Comfort
Verbalizes pain level on 0-10 scale: 6                      Location: right knee
Quality: sharp                      :
Comments:
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Head & Neck
Oral cavity:         moist                     
Sclera/conjunctiva:           clear      
Pupils:                   equal     
Pupil reaction:                    R: brisk    pupil size: 2mm
L: brisk    pupil size: 2mm
Comments:
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Chest:
O2Sat:   97%        Respiratory rate: 20                    Respiratory effort:   easy, no difficulty          
Breathe sounds:                  equal      clear       bilateral   
Cough:                  n/a         
Oxygen:                                n/a         
Chest tube:                                          
Comments:
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Heart sounds:
Apical pulse: 84             regular                   
Comments:
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Gastrointestinal
Abdomen:          soft         nondistended       
Bowels sounds:                    active x 4 quadrants          
Comments:                
Last BM: yesterday                           
Comments:
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Genitourinary
Urine:                    voids: 
Urine color: yellow,  clear    
Comments:
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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:  less than 3seconds
Comments:       
Handgrips:           equal/bilateral
R:            strong    
L:            strong    
Movement upper extremities:         equal/bilateral
R:            strong    
L:            strong    
Movement lower extremities:         equal/bilateral
R:            strong    
L:            strong    
Comments:       
Sensation:              present/appropriate           
Comments:
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Integument
Skin:      dry          warm     
Color:    WNL   
Turgor: elastic   
Nailbeds: pink                                                    
Edema:                 other:     Right knee
Comments: Infected
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IV sites
IV start date: today’s date
peripheral-catheter gauge: 18g         Location: Left FA
IV infusing- ½ NS @ 50ml/hour  pump #: 4321
no redness occlusive dressing intact
Comments:
   Wounds/incisions                           
Location: right knee
Dressing: n/a (OTA)          
Drainage: none
 Describe: red/swollen
Comments: infected
Drains/Tubes :n/a     

Fall Precautions:  n/a     
Decubitus Precautions      n/a