Shadow Health - Robert Hall - Mobility -
Objective
Assessed V itals - ANS T emperature: normothermic
Heart Rate: no abnormal findings
Respiratory Rate: no abnormal findings
O2 Saturation: no abnormal findings
Assessed Orthostatic Blood Pressure - ANS Blood Pressure at Rest:
normotensive
Evidence of Orthostatic Hypotension:
-systolic decrease of >= 20 mmHg
-diastolic decrease of >= 10 mmHg
Assessed IV Bag - ANS Appropriate Fluid: bag is normal saline
Appropriate Label: name and dosage are correct
Fluid Appearance: no visible abnormal appearance
Assessed IV Pump - ANS Observations: IV pump is infusing IV fluid at the
ordered rate
Assessed IV Site - ANS Insertion Site: no visible abnormal signs Dressing: dry and intact
Inspected Head and Face - ANS Skull Symmetry: symmetric
Facial Feature Symmetry: symmetric
Appearance: no visible abnormal findings
Inspected Eyes - ANS Eyelids: no visible abnormal findings
Conjunctiva and Lens: no visible abnormal findings
Pupillary Reaction: no visible abnormal findings (PERRL)
Accommodation: normal constriction and dilation
Inspected Mouth - ANS Oral Mucosa and Gums: moist and pink, no bleeding
Lips: dry appearance, chapped
Tongue: dry appearance
Inspected Skin - ANS W ounds or Sores: no abnormal findings
Signs of Skin T rauma: bruising
Color or Appearance: redness
Masses or T exture: no abnormal findings
Skin Characteristics and Hair Growth: no abnormal findings
Inspected Thighs - ANS Right: Appearance: no visible abnormal findings
Left: Appearance: bruising or other discoloration
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