Assessment Findings

0800: VS- 97.7/100/16, BP 128/76 in left arm, O2 sat 93%. Pt. alert, oriented x3. Skin pale, warm to cool, dry, intact. Eccymosis diffuse over right lateral thorax. MM moist, pink, intact. Nail beds pale pink, <3 seconds. Radial pulse 2+ bilat., PP 2+ bilat. Lung sounds clear bilat. ant/post. Abdomen soft, flat, bowel sounds present x4. IV in right forearm, occluded. Pt. c/o pain of 7/10 in right shoulder area radiating down to his right side ribs. Oxycodone (10 mg) administered. 0900: Pt. rates pain at 1-2/10, and is more comfortable now. Pt. taught cough and deep breathing and encouraged performing this every hour. 1200: Right forearm IV dc’d, catheter intact. 1300: C/o pain 5/10 Lortab (1 tablet) given. 1345: Pt. rates pain on 0/10 and is more comfortable. VS: 99.2/84/16, BP 126/58, O2 sat 93%. All other assessments remain unchanged.