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Physical Assessment Pain labored facial expression, pt states “I am very out of breath” Pt observed sitting in chair in tripod position Speech slow, pausing for breaths between words VS: 100-89-24-138/92-88%-room air ...

Physical Assessment Pain labored facial expression, pt states “I am very out of breath” Pt observed sitting in chair in tripod position Speech slow, pausing for breaths between words VS: 100-89-24-138/92-88%-room air Skin: pallor, dry, wrinkled Mucous membranes: dry, pale Braden Score – 12, Redness noted on sacral region, unblanchable Pt requires x1 assist with all ADLs Facial features symmetric, noted nasal flarring Pt denies difficulty swallowing, cranial nerves intact No lymphadenopathy Pt denies any difficulty swallowing Orientated x4 LOC- lethargic, easy to rouse Upper extremities weak bilaterally, Lower extremities weak bilaterally PERRLA-no abnormal findings Capillary refill > 3 sec, clubbing on both hands Edema +2 lower extremities Respiratory rate 24, tachypnea, labored, rapid, shallow Noted accessory muscles used for breathing Breath sounds wheezing and crackles Dyspnea, SOB on exertion, Oxygen 2L nasal cannula Noted productive cough, yellowish sputum Able to clear secretions on own, hypoxic Abdomen soft round, hypoactive BS x4 Hard formed stool 2 days ago Pt can feed self, general diet, pt states “I don’t feel like eating” Pt incontinent of urine, no pain or bladder tenderness No bladder retention, urine yellow clear Active ROM, High Fall Risk, walker used for ambulation Pt reports waking often at night with dyspnea Sleeps in chair, orthopnea – 2 pillows Pt lives w/ son in single family home, 6 stairs to enter Pt experiencing anxiety over living situation Pt states that she is worried about the financial burden she is putting on her son Infection Control & Safety