Head To Toe Assessment

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0800 Pt up sitting in dining room for breakfast, good appetite this morning ate 100% for her breakfast…………………………………………………L.Gotora PNS1/WATC 0900 Pt went to church with the assistance of social worker………………………………... ………………………………………………………………….L.Gotora PNS1/WATC 0930 Pt back from church current in room. Head to toe assessment completed. A&OX1. Vital sign T 98.8 F left ear tympanic, P 78, R28, BP 120/80 and O2 94 RA. Pt denies any pain and rated 0 on scale of 0 to 10. No sign of discomfort presented. Pupil equal and react bilaterally to light. Hair dry and clean without scalp. Ears clear without redness and swelling, no hearing aids, medium amount of cerumen in ear canal. Nares redness with small drainage. Report the finding to charge nurse Dentition

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