0800 Pt in room up sitting on wheel chair getting ready for breakfast. Ride Pt to dining room and ate 80% of his breakfast…………………………L.Gotora PNS1/WATC
0900 Focus assessment completed. Pt in bed lying down call right within reach. Alert and orient x4. No sign of distress or discomfort at this time. VS T96.9, P84, R 20, BP 102/67, O2 Sat 96% RA. Pt denies pain at this time. Heart rate sound regular and even, S1 and S2 auscultated. Lung sound clear in all lobes, respiratory even and none labored. Bowel sound active in all four quadrant. No tender to touch and palpable masses. Pt reported no bowel movement this morning. Patient has a picc line on right arm dressing on PICC site dry and intact no redness or swelling noted wound to left lower extremities