Name:            Peggy Red                Pt. ID#: 0000004       Bed: 429        
Admitting diagnosis: Cirrhosis                  Admitting physician: Dr. Doolittle
Allergies: Codeine, Hydrocodone, Tramadol, Cyclobenzaprine
Today on admission:

Admission Assessment
Mental Status
alert & oriented to person, place, time
Mood & affect:                   pleasant     anxious    
Behavior:             cooperative    
Comments: drunk
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Pain/Comfort
pain 
Verbalizes pain level on 0-10 scale: 8                      Location: abdomen
Quality:                 dull         aching    :
PCA-#               PCEA- #                intrathecal
Medication & settings:
Comments: same as last admission______________________________
Head & Neck
Oral cavity:         moist     
Sclera/conjunctiva:           yellow:     
Pupils:                   equal     
Pupil reaction:                    R: brisk    pupil size: 4mm
L: brisk    pupil size: 4mm
Comments:
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Chest:
O2Sat:   93           Respiratory rate: 20                    Respiratory effort:   easy, no difficulty          
Breathe sounds:                  equal      clear       bilateral   
Cough:                                  nonproductive     
Oxygen:                                n/a         
Chest tube:                           n/a           
Comments: heavy smoker
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Heart sounds:
Apical pulse: 90             regular                     
Comments:
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Gastrointestinal
Abdomen:          firm        distended               tender 
nausea   emesis –describe:   green thin liquid   
Bowels sounds:                    hypoactive x 4 quadrants                
Comments:                
Last BM: yesterday                           
Ostomy:                                n/a         
Tubes:                   n/a         
Feeding:                n/a         
Comments: ETOH
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Genitourinary
Urine:                    voids:  no
Urine color: dark 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 3 seconds
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:         
Equipment:          TED n/a                 SCD: # n/a       Plexy-pulse:# n/a            CPM: # n/a
Traction: n/a       
Comments:
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Integument
Skin:      dry
 
Color:    jaundiced     
Turgor: elastic   
Nailbeds: pink                    
Edema: n/a
Comments:
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IV sites
IV start date: today
peripheral-catheter gauge: (18g)      
Location: R hand
IV infusing- fluids & rate: NS @ 50ml/hour                   pump #: 1234
no redness,      occlusive dressing intact
 Comments:
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Wounds/incisions: N/A
Drains/Tubes: N/A     
Isolation: N/A     
Comments:      
Fall Precautions: Yes                       
Decubitus Precautions: N/A