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This Concept Map, created with IHMC CmapTools, has information related to: rataycmap5, JB Priority Nursing Diagnoses, JB ???? Patient Information, JB ???? Medications, Last Bowel Movement 02/22/08 Abdomen firm, non-tender, & distended. Bowel sounds present x4 quadrants. Suprapubic catheter intact and draining amber urine. He is incontinent of stool Gastrointestinal Genitourinary Physical Assessment, Medications ???? Hospital, PERRLA, pt is A&O x3. Generalized muscle atrophy, only able to move left hand. Pt is unable to sit up or walk. He is able to turn his head side to side but not shrug his shoulders. Neuromuscular Musculoskeletal Physical Assessment, JB has a Past Medical History, History of Present Illness as of 02/27/08 JB, Temp: 36.0 BP: 102/62 Resp: 22 HR: 62 SpO2: 94% Pain: 0/10 Vital Signs Physical Assessment, Physical Assessment JB, Diagnostic Tests related to History of Present Illness, Skin is dry and intact except for midline and diagonal abdominal incisions. Healed skin ulcer open to air on sacrum. Braden = 12 (sensory perception: 2; occasionally moist: 3; activity: 1; very limited mobility: 1, nutrition:3; friction and shear: 1). Skin is pale and cool, but shows signs of adequate tissue perfusion. Integumentary Physical Assessment, Lung sounds diminished bilaterally. Productive cough with white, yellow, & green sputum. Expiratory wheezes in lower lobes bilaterally, rhonci in upper lobes bilaterally. Pulse ox stable on 40% trach mask. Respiratory Physical Assessment, Medications ???? Home, Abnormal Labs related to History of Present Illness, Heart rate & rhythm regular. Peripheral pulses palpable at 2+. Capillary refill ɚ sec. S1 and S2 heart sounds auscultated. Hemodynamic vital signs stable. Cardiovascular Physical Assessment, Pt needs total care with bathing, toileting, and oral care. Pt is unable to sit in a chair or walk in the halls. Functional Physical Assessment, Pt is unable to participate in his care. No family is currently present at the bedside. Pt does not seem to be coping, appears depressed. Psychosocial Physical Assessment