Narrative Notes Clinical Week 1

.docx

School

Galen College of Nursing *

*We aren’t endorsed by this school

Course

3160

Subject

Medicine

Date

Apr 3, 2024

Type

docx

Pages

Uploaded by BaronMusicStarling20

NARRATIVE NURSE’S NOTE 8 Jan 2024 – 10:30am: Pt. A/OX2, lethargic but able to follow basic commands. PERRL was unable to be assessed, pt. refused, no hearing deficit noted. Pt. does not indicate pain. Oral mucosa dry/pale. Abdomen soft/non-distended, G tube and ostomy present in pt. left upper quadrant. Pt. presents with foley catheter, with 400cc of dark, cloudy urine. Bilateral hand tremors are present. Bilateral edema present in LE. Skin inspected, no redness or skin breakdown noted on anterior of pt, dryness on abdomen LE and UE. No IV. VS obtained: B/P refused by pt., pulse 94, RR N/A, Temp. 98.2, SpO2 98 on room air. Pt. has generalized weakness and expressed pain when palpating bilateral LE. ------------------------------------------------------------------------------------------K.Sachs, SBSN

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