Western Regional Hospital

Assessment
Part I Patient Information
Patient Name: Jones John BHIS Number:000321 Phone number: 684-5289
Email:
johnjones123@gmail.com
DOB :6/14/1971 Age 52 Weight:250 LBS /113.4 kg Height: 5’10/1.78M
Allergic: PCN Gender: Male
Language preference: Correspondence Preference:
English: Phone Calls:
Spanish: Email:
Other:
Part II Vital signs
Temperature: 98.6°F / 37°C
Pulse Rate: 82 bmp
Respiration Pressure: 17 bmp
Blood Pressure: 120/80 mm Hg
Pain:0

Assessment time: 8:02 am Nurse notes

Date: 11/17/23
Discipline: Nurse
General Appearance
Pt is calm Affect and their facial expression is
Affect, facial expression, posture, appropriate to the situation. Pt do not observe OOB.
gait Speech clear.pt placed in supine position
Speech

Skin Skin is mostly warm and dry. Pt complaints of itchiness

and pain in the abdominal.
Color, texture, hygiene, moisture Pt clean in good care condition
Pt hands and feet are clean
Intactness, lesions, breakdown

Room and equipment Lr at 125 ml/hr in 18 gauge PIV. midline incision

drained 20 ml sanguineous fluid, drain reactivated
IV fluids, IV access Has NGT placed in his nares
Tube feedings Iv connection changed 1/11/23 .
Drains, Foley Tube clean
No bleading
Iv connection show no sign of redness
Neuro Oriented x4. Grips, flexion, extension strong bilaterally.
Movement of the mouth and well clean .
LOC, pupils No sign of bleeding
Hand grips
Feet – flexion, extension

Psy/ Soc Lives with wife, who will be caregiver as needed upon
discharge
Family/ support systems

Pain Pain noted at 1 on the number scale. Pain medication

Intensity (specify tool)
Location, character
Associated signs/ symptoms
Pain interventions and effectiveness
Rest/ Sleep
Usual pattern/ changes since
hospitalized
administered and pain noted at 3 on same scale 30
minutes later.
Pt have two bandaged lesions in both upper thights
Leg had no signs of bleeding
Pt reported no sleep problems other than hospital
required interruptions.