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Post Conference JC 7/16/19 (Head to toe (Other (LOC X4, can ambulate with…
Post Conference JC 7/16/19
Head to toe
vitals:
Heart Rate: 62 Respiration: 17 Temperature: 97.9 B/P: 156/73
Chest
Barrel chest.
use of accessory muscles of breathing: shoulder and abdomen
Head
PERLA, clear sclera, dry secretions inside nose. no drainage in ears.
Arms
symmetrical heart rate,
numbness and tingling on hands
turgor= less than 2 secdns
Peri Area
Last BM 7/15 and last voiding afternoon 7/16. no abnormalities noted, no foul smell.
Legs
no sensation on righ feet
edema noted both feet
Lung sounds = clear
hear sounds= regular and strong
Other
LOC X4
can ambulate with walker
weakness on both legs
calm and hopeful
Finished all meals except lunch
History
Tracheostomy, gastrostomy
Primary dx: Acute respiratory failure with, hypoxia
Chronic: DM 2, COPD
Pain
back of neck
on fingers
big toes on both feet
improvement = listen to lung sounds for a full inhalation and exhalation
listen to the first 3 breath, compare each