Pt 2 Nurse Notes

DATE/TIME 4/ 14/2 008

071 5 081 5

NURSE'S NOTES PT ate 100% BF with total assist, some dysphagia. Complete bed bath / linens changed / oral cavity swabbed w/ oral glycerin swab. Oral mucosa pink slightly moist - gave pt sip of water. HEENT: small 1in scab on (L) temple. Eyes clear/ glassy, upper lids un-symmetric: (R) r/t CVA, (L) WNL, unable to follow 6 gazes, can follow voice and faces. AOX1 unable to assess orientation to time and place due to aphasia, and end stage dementia, r/t CVA. Abdomen: soft hyperactive bowel sounds in all 4 quadrants: Breasts, symmetric in shape and size, no palpable masses or visible lesions. Midline scar on sternum 10 in vertical. Skin intact on upper body, contractures of (R and L) arms and hands. ROM performed as tolerated to pt. Back massage given during bath: Desitin applied on buttocks, some redness noted around rectum.

083 0

x1 large BM, cleaned pt, changed bed pad, applied desitin to buttocks turned to rt side with wedge under back.

1000

dressing change: wet to dry w/ acetic acid packing to Stage IV decubitus ulcer on (L) lower buttock, 4'L x 3'W x 2'D tunneling of 1' on superior edge, Wound cleaned w/ NS, wound bed pink very little clear discharge, after packing w/ acetic acid pack covered w/ 6 x 8 inch derm/ coverpad.

120 0

Ate 100% lunch with total assistance, 8oz sweet tea, 2oz water V/S BP 108/58; P (rt radial) 78 palpable and regular rhythm; Respirations 18; Temp N/A. Applied splint to (L) hand, (R) hand gripping rolled washcloth. All pulses palpable and regular rhythm; lungs clear bilat. bowel sounds WNL and present all 4 quadrants. Turned pt on backside adjusted legs: Removed socks no pitting edema; Bilat plantar flexion of feet. Pt dry, warm, watching Gospel music channel.

BSCC MEDICAL CENTER MOBILE, ALABAMA