[Solved]: You are taking care of Ms

You are taking care of Ms. Mercy P. Diem. You complete a chart review, take note of current orders and enter the patient’s room to introduce yourself . You note that Ms. Diem is awake, but lethargic when you enter. She looks up at you and has her hand on her abdomen. You notice guarded movement with adjustment in bed and bracing her abdomen. Her respirations are approximately 14. She reluctantly allowed you to auscultate her abdominal quadrants and palpate her abdomen. Her BP is 132/84 and heart rate is 92. Pulses are all present, 2+ in upper extremities and 2+ in the pedal region. Capillary refill is less than 2 seconds. No edema noted. Bowels sounds are hyperactive and abdomen is distended. Abdominal pain is 5/10. Active ROM and muscle strength is 2+ in all extremities. No skin breakdown noted. Independent with ad lib activities. IV line in right forearm flushed with no issues and IV fluid running. Document an SBAR note with the findings.