Peri-area skin currently clear and intact, with no areas of redness. At risk for skin breakdown related to limited mobility and incontinence, at risk for pneumostatic pneumonia due to limited mobility, TCDB q 2 hr, up in chair TID with assist of 2 people. At risk of DVT due to immobility, TEDS on bilateral, Active ROM Right leg, Passive ROM left leg, q 4 hours. Calf pumps x 5 bilateral encouraged every 2 hours while awake. Homans sign negative bilateral.
Pedal pulses palpable bilateral.
Feet cool, dry, intact, with thick toenails bilateral. Positive 100 cc for this shift. This page created and maintained by Mary Bennett DNSc, RN Home Teaching Research Distance Education Student Support Medline et al.