ASSESSMENT

• NEURO: A&O x4, Speech is clear, mood is pleasant which matches her affect. Head is normo-cephalic, no lesion, infestations, lumps or masses present upon palpation and inspection. Eyes, eyebrows, & eyelashes are evenly distributed. Facial features are symmetrical. PERRLA intact. Cranial nerves intact.  
• RESP: Lung sounds clear to auscultation anteriorly & posteriorly. No wheezing, rattles, or rhonchi present. No accessory muscle usage, no signs of distress. Speech is clear.
• CV: Palpated Carotids- 2+ equal bilaterally, no JVD, carotids clear to auscultation- no bruits heard. S1, S2 present, no S3 or S4, no murmurs. Radial pulses 2+ equal bilaterally.
• GI: Abdomen symmetrical bilaterally, flat, and non-tender. Umbilicus is inverted, midline, with no discoloration or herniation. Active, gurgling bowel sounds in all four quadrants upon auscultation. No bruits noted, no masses or distention.
• GU: Client is continent of B/B with occasional periods of incontinence at night. Denies burning, irritation, discharge, or frequency. Previous hx of UTIs. Client wears attends throughout the day/overnight. Reports urine clear, pale yellow, non-odorous.
• Skin: Clear, warm, free of lesions, rashes, edema, & ecchymosis. Color appropriate for ethnicity, no tinting present. Skin turgor has appropriate elasticity, nail beds pink, no clubbing, cap refill < 2 secs.  
• M/S: Pedial and post tibial pulses 2+ equal bilaterally. There is slight spinal curvature. No swelling, bruising, or tenderness over lower muscles and joints. Mild tenderness of upper muscles. Passive ROM appropriate for age. 4/5 strength of bilaterally of upper and lower muscles......... Continue