Pt lying in bed, with gown on, A&O x3. Responds to verbal stimuli.

T 37, P 68, reg, S1,

S2, R 18 easy and unlabored, BP 117/68. Denies pain. PICC L AC IV @ 50 ml/hr. no s/s of
phlebitis or infiltration. Cap ref brisk <3 sec. PP 2+, skin turgor brisk, skin color appropriate for
race, warm, dry. Neg Homans. No s/s of edema. Hair is neat, clean, and without odor.
PERRLA. Conjunctivae pink. Nares are patent and moist. Mouth is moist and free of odor. All
teeth present, tongue is pink. LS clear A&P bil. SPO2 95% RA, denies cough and SOB. Abd
soft, nontender, nondistended. BS + x4. Hand grips equal. Moves all extremities freely without
pain. Skin intact throughout, without redness, erythema, or bruising.