VIEW COMPLETED NOTE

Admitted Date: 2022-07-01 at 17:46. PATIENT INFORMATION: Patient is 78 year old Female, Transferred from Jackson Hospital, via ambulance, requiring 2 person staff assist with transfer from the stretcher. MEDICAL CONDITION/RECENT HOSPITAL STAY. Primary diagnosis : UTI, Parkinson. Other Diagnosis: COPD. Language: English, Portugues. Advance Directives: Full Code. Allergies: Iodine. ASSESSMENT: Patient is Alert, disoriented, but can follow simple instructions, Sight: Impaired, Hearing: Normal. Responsive to touch and verbal orders, presents with adequate hearing and speech clear. Affect and facial expression appropriate to situation. Grips, flexion, extension strong bilaterally., Respiration even and unlabored. No accessory muscles used. Breath sounds clear in all areas. Chest expansion symmetric. No pain or tenderness on palpation. Percussion tones resonant over all lung fields. Vesicular breath sounds auscultated over lung fields. No adventitious sounds present., Heart sounds: Regular rate and rhythm: S1/ S2 normal; no murmur, rub or gallop. Peripherals pulses present and normal. The jugular veins are not visible. No edema. Capillary refill <3 sec., Abdomen soft, non-tender, non-distended, bowel sounds present in all quadrants., right hemiplegia. VITAL SIGNS taken as follows: Blood Pressure 120/80 mm Hg, Pulse 66 bpm, Respiratory Rate 18 bpm, Temperature 97.2 °F, 02 Sat 98 %. Pain: right hand, 4/10. Skin: red rash perineal area. PATIENT HEALTH STATUS: Bladder: Incontinent, Bladder Device: Foley Date Catheter inserted: 2022-07-02. Bowel: Incontinent, Ostomy: Colostomy, rigth side, Date of Last BM: 2022-07-02. NUTRITION / HYDRATION: Diet: No Added Salt (NAS), No Concentrated Sweet (NCS), Low Fat, Eating: With Assistance, Tube Feeding: No Tube Feeding. PHYSICAL FUNCTION: Ambulation: Ambulates with assistance, Transfer: Assistance with 1 Assistant, Devices: Wheelchair, Walker, , Weight-bearing, Left: Partial, Weight-bearing, Right: Partial. RISK: Risk Alerts: Falls, Limited/Non weight bearing: (left, right), Immunizations: , Isolation Precautions: Contact, Types of Isolation Precautions: MRSA, none. TREATMENTS: Types IV: None, Date inserted IV: . Respiratory Delivery Device: Nasal Cannul, Oxygen: 2 LPM continous, Other Treatments: Pacemaker. Personal Belongings: Contacts, Eyeglasses, Hearing Aids, Dentures, pair socks.