The patient’s head was normal in size and shape with all normal features present. The hair on the patient’s head and face was evenly distributed, with no lesions, infestations or dandruff. The hair on the back of the head was discolored from the iodine used during surgery to clean the patient’s neck. The patient’s hair was soft, short and silver in color. The eyes, nose, mouth and ears of the patient were symmetrical and at even levels bilaterally. The skin of the patient’s face was soft, non-tender, warm to the touch, dry, and free from lesions. No abnormal findings were found when palpating the patient’s skull. Since the patient was sedated and intubated, cranial nerve five could not be tested.
The eyebrow hair and eyelashes on the patient …show more content…
The patient’s skin temperature was warm and his skin surface was dry with good skin turgor. His body hair on his legs and arms was even in distribution. The patient’s surgical neck wound could not be assessed due to his neck being in a support brace, and his surgical wound on his lower back could also not be assessed. The dressings on the patient’s back and neck were listed in his chart as mepilex dressings. Two Jackson-Prat closed suction drains were in place, one in his neck wound and one in his back wound, with both of them containing sanguineous drainage. No other lesions were noted on the patient’s skin. The patient had an eighteen-gauge peripheral intravenous therapy line in the right antecubital that was placed upon admission. He also had a double lumen, seven French-gauge central venous catheter in the right femoral artery place on 10/3/16, and an arterial line placed in the right radial artery on 10/3/16. There was slight edema noted on the patient’s lower extremities bilaterally with a grade of 1+. The nails on the patient’s hand and feet were flat, smooth and intact, with pink nail beds and overall healthy appearances. The patient’s capillary refill was less than three seconds. No clubbing of the patient’s fingers was noted. There was no blanching or redness of the patient’s skin on his bony prominences. The patient had a Braden scale score of eight, due to his inability to change body …show more content…
His inspiration and expiration appeared to be the same length, with even chest expansion. The patient’s oxygen saturation was around 95%. No complications were noted during the percussion of the patient’s chest. Auscultation of the patient’s lung fields revealed diminished breath sounds with some crackles in the base of the left lung. The patient had a non-productive cough, and suctioning resulted in a large amount of thick clear, white secretions. The patient tolerated the suctioning procedure well.
The patient’s apical pulse was irregular in rhythm. Upon auscultation of the heart, S1 and S2 sounds were noted, as well as an irregular heart rhythm. No murmurs were noted. All of the patient’s extremities were warm, with slight edema noted in the patient’s lower extremities. Capillary refill of the patient’s hands and feet were less than three seconds bilaterally. The patient was on continuous telemetry with the alarms on, and an abnormal sinus rhythm was