DATE/TIME NURSE'S NOTES

4/ 14/2 008 071 5 PT ate 100% BF with total assist, some dysphagia.

081 5 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