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• Patient weight 97.3 kg • Surgery repeated 07/22 persistent fever Assessment • General: Lying bed, anxious, appears big for his age, weak and drowsy; mom and grandma at bedside • Vital Signs: 1930: BP 110/64, RR 16, HR 104, temp 99.6, O2 95 room air, pain 4/10; 2330: BP 130/70, RR 16, HR 108, temp 100.0, O2 94 room air, pain 7/10; 0330: BP 118/60, HR 98, RR 18, temp 99.6, O2 96, pain 3/10 • Neuro: AOx3, speech is clear, talk slow, response is appropriate • HEENT: head normocephalic, eyes, ears, nose symmetrical, PERRLA, mucus membrane dry no dry no drainage • Cardiac: S1 S2 present, nor mal rate and rhythm, no murmurs • Respiratory: regular rhythm, dimmish sound at the bases bilaterally • Neurovascular: no paralysis, pallor noted • Peripheral vascular: pedal pulses weak and thready, radial pulses 2+ equal bilaterally, lower extremity edema +3, CRT 3 seconds • GI: NPO, hypoactive all quadrants, lower abdomen incision with clean dry intact dressing, with wound vacuum attached • GU: void twice during my shift. 80 mL and 90 mL dark amber color, malodrous • Integumentary: cool, pale skin, dry surgical incision in the lower abdomen, small wound on the tip of nose noted (from NG tube, 2 days ago. • Musculoskeletal: on ECT sleeves, • Psychosocial : developmentally appropriate for age: mom, grandma, dad at bedside. • IV/Lines: left antecubital IV 24-gauge, patent, dry clean intact dressing, no tenderness • Drains/Tubes: wound vacuum – moderate amount of serosanguinous flu
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