The Presbyterian Hospital
          in the City of New York
   Columbia - Presbyterian Medical Center
         New York, NY 10032 - 3784

   NURSING DATA BASE FLOWSHEET
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DATE   8-26-93                            7P   TO: 7:30/A
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NEUROLOGICAL
Patient is awake, alert & oriented X 3.  Patient understands & follows
instructions fairly well.  Pupils are equal & reactive to light
Able to move all extremities.
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PSYCHOLOGICAL
  pleasant & cooperative

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RESPIRATORY
Breathing easy and spontaneous on Room air.  Breathing Sounds
audible & clear   Intact.   No cough noted. No complaints
of shortness of Breath.  Respiratory Rate 16/min
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CARDIO-VASCULAR
cardiac monitor     shows Normal Sinus Rhythm without ectopy
Heart Rate 98/minute   B/P 134/86  (-)edema in extremities.
Peripheral pulses are present & palpable.
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GASTROINTESTINAL
 (nurse records observation on another patient here by mistake. She 
states, "error, see next side - patient progress note- for assessment").
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GENITO/URINARY
Foley to gravity drainage  (?without vital sign fluid sheet)

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INTEGUMENTARY
Dry and intact.  Abrasions on face.  drying & healing - No
drainage observed.  Right pulses.  Sl(ight) edema near IV site
secondary (to) infiltration right arm
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MUSCULOSKELETAL
  Able to move all extremities well

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COMFORT
No complaints offered.

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REPRODUCTIVE
  No penile discharge

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                              SIGNATURE(Ramierez)      TITLE RN

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