Assessment: Vital : signs T 98.0, P 75, BP 137/54, SpO2 96, R 14
A&O x4, pleasant
Pain 3 out of 10
PERRLA- 3, Round, Reactive, EOM X6 , facial features symmetrical, tongue midline
Muscular- Full Range of motion, R&L upper and lower strength x5 strong
Respiratory- lungs clear and breath sounds symmetrical
Cardiac- S1 and S2 heard clearly
Peripheral Vascular- radial pulses 3+, pedal pulses 2+, nail beds < 3 seconds , no cyanosis
Integumentary- dry, appropriate for skin color, no tenting, no edema present
GI-round, active bowel sounds in all four quadrants, tender, abdominal incision
IV assessment- no redness, clean, dry, intact
Gait- unbalanced at first, slow