**NextGen Practice and Understanding

Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases.

Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases. Productive cough is noted. S1 and S2 are auscultated, and S3 is noted. Radial pulses are strong; pedal pulses are thready. Capillary refill is greater than 3 seconds. There is +2 pitting edema in bilateral lower extremities. Skin color is pale, and skin is cool to touch. Muscle strength is weak in bilateral upper and lower extremities. Abdomen is distended, bowel sounds are present in all four quadrants, and there is no pain on palpation. 

Temperature: 98.2° F (36.8 ℃)

Heart rate: 122 beats/minute

Respirations: 32 breaths/minute

Blood pressure: 168/96 mmHg

Oxygen saturation: 88% on room air

The client is a 63-year-old female who arrived in the Emergency Department accompanied by her spouse.

0700 Triage RN Notes

The client is a 63-year-old female who arrived in the Emergency Department accompanied by her spouse. The client reports fatigue over the last 2 weeks and increasing shortness of breath as well as difficulty sleeping in bed. States has been unable to lose weight and seems to be gaining about 3-5 pounds per week, and has had minimal urinary output the last few days.

Past Medical History

Type II diabetes for 10 years

Coronary Artery Disease

Hypertension

Hyperlipidemia

New York Heart Association Class II Heart failure

Chronic Obstructive Pulmonary Disease

Past surgical history of cholecystectomy and gastrectomy

No known drug allergies

Social

Drinks 2-3 alcoholic beverages daily

Smoker, 2 packs per day for 5 years

Client’s Home Medications: 

Metformin 500 mg orally daily 

Lasix 20 mg orally daily

Lisinopril 20 mg orally daily

Pravastatin 40 mg orally daily

Metformin 40 mg orally daily

Aspirin 81 mg orally daily

Physical Assessment:

Neurological: Alert and oriented x 4

Respiratory: Bilateral crackles half up, labored breathing

Cardiovascular: S1, S2, S3 gallop noted, irregular rhythm, apical/radial difference, palpable 1+ peripheral pulses, +1 edema in the lower extremities, delayed capillary refill. 

GI: abdomen large, firm, distended, + hypoactive bowel sounds all 4 quads.

GU: Nocturia

Integumentary: skin pale, diaphoretic, cool to touch

Brain Natriuretic peptide 

Complete Blood count

Cardiac enzymes

Blood gases 

Blood glucose monitoring Q 6 hours 

Basic Metabolic Panel

Hemoglobin A1C

Triglycerides

HDL 

LDL

Urinalysis

Stat Portable chest x-ray

Stat Electrocardiogram

State Echocardiogram

Start Intravenous line

Vital signs per protocol 

Cardiac monitoring per protocol

O2 at 4 liters per minute, simple mask, adjust O2 to maintain O2 sat greater than or equal to 92%

0700 

Temperature 98.6 F , BP 160/110 mm Hg, Heart rate 155 BPM RR 36 O2 Saturation 84% on room air. Height 5’4”, 220 pounds (100 kg).

The client arrives at the emergency department with a diagnosis of congestive heart failure. The paramedic states that the client is demonstrating signs of poor perfusion.

1800

The client arrives at the emergency department with a diagnosis of congestive heart failure. The paramedic states that the client is demonstrating signs of poor perfusion.

• Alert and oriented to person, place, time, and situation
• Promptly follows commands
• Altered mental status

1800

• Hypotension
• Bounding peripheral pulses
• Skin warm to touch

• Urine output less than 30 mL/hr
• Reduced urine osmolality
• Increased urine specific gravity

A 62-year-old male arrives at the emergency department accompanied by his wife. He reports increased shortness of breath with daily activities and exertion and feels more fatigued than normal. The nurse has reviewed the client’s history and physical and has documented his reported information regarding the purpose of his visit. The nurse is now determining the relevant information in order to address the needs of his acute condition.

The client reports the purpose of his visit is his increased shortness of breath and fatigue for the last two months. Increased work of breathing was noted with ambulation to the stretcher. Skin is pale and diaphoretic. The client states, “I gained 3 pounds this week without changes to my diet or activity routines. In fact, I don’t really have much of an appetite at all because I usually feel full.” He states that his shoes feel tight. Upon taking off his shoes, the nurse notices his socks leave an indentation around his ankles. The client also mentions an increase in urinary frequency overnight. 

Client is sitting on stretcher with head of bed at 60 degrees. Increased work of breathing and pale skin color are noted on initial inspection. Cardiac monitoring and pulse oximetry initiated per department protocol.

1210

Client is sitting on stretcher with head of bed at 60 degrees. Increased work of breathing and pale skin color are noted on initial inspection. Cardiac monitoring and pulse oximetry initiated per department protocol. Vital signs taken per triage note. Client reports the purpose of his visit is his increased shortness of breath and fatigue for the last two months. Increased work of breathing noted with ambulation to the stretcher. Skin is pale and diaphoretic. Client states, “I gained 3 pounds this week without changes to my diet or activity routines. In fact, I don’t really have much of an appetite at all because I usually feel full.” He states that his shoes feel tight. Upon taking off his shoes, the nurse notices his socks leave an indentation around his ankles. Client mentions an increase in urinary frequency overnight. 

1215

Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases. Productive cough is noted. S1 and S2 are auscultated, and S3 is noted. Radial pulses are strong; pedal pulses are thready. Capillary refill is greater than 3 seconds. There is +2 pitting edema in bilateral lower extremities. Skin color is pale, and skin is cool to touch. Muscle strength is weak in bilateral upper and lower extremities. Abdomen is distended, bowel sounds are present in all four quadrants, and there is no pain on palpation.

1225

Healthcare provider is at bedside evaluating client.

1235

Client is placed on 5-lead cardiac monitor, and 4 L oxygen via nasal cannula are applied. 18-gauge IV catheters are placed in left wrist and right antecubital and flushed without resistance. Client tolerated well. Blood collected for ordered laboratory testing. Chest X-ray and echocardiogram are completed. 12-lead electrocardiogram performed.

1305

Client is anxious, reporting increased shortness of breath. Client is placed on non-rebreather mask at 10 L per minute of oxygen. Client is currently coughing up pink frothy sputum. Crackles are present in all lobes bilaterally.

1310

Laboratory and diagnostic results are posted to the electronic heath record. Healthcare provider contacted regarding client’s changing condition.

Chest X-ray: cardiomegaly, diffuse pleural effusions

Echocardiogram: left ventricular ejection fraction 35%

Electrocardiogram: sinus tachycardia, left bundle branch block, left axis deviation

Initial Orders 

Complete blood count

Basic metabolic panel

Cardiac enzymes

Brain natriuretic peptide

Chest X-ray

12-lead electrocardiogram

Echocardiogram STAT

Place IV catheter.

Initiate supplemental oxygen.

Titrate to saturation greater than 92%

Continuous cardiac monitoring 

Admission Orders

Furosemide 40 mg IV once

Morphine 2 mg IV every 4 hours as needed

CPAP 40%, 10 cmH2O, RR 12

Place indwelling urinary catheter

Intake and output every hour

Vital signs every hour

Furosemide 40 mg orally twice per day 

Potassium chloride 20 mEq orally twice per day

Lisinopril 40 mg orally once per day

Carvedilol 25 mg orally twice per day 

Simvastatin 20 mg orally once per day

Aspirin 81 mg orally once per day

Tiotropium 2.5 mcg inhalation 2 puffs once per day

Admit to Telemetry Unit

Cardiology consult

Chest X-ray in a.m.

Basic metabolic panel at 1800 today and in a.m.

Fluid restriction 1,500 mL per day

1200

Vital signs

Temperature: 101.3° F (38.5℃)

Heart rate: 127 beats/minute

Respirations: 29 breaths/minute

Blood pressure: 162/92 mmHg

Oxygen saturation: 90% on room air

Pain: 3 out of 10 on the numeric pain scale located primarily in the chest 

1215

Vital signs

Temperature: 98.2° F (36.8 ℃)

Heart rate: 122 beats/minute

Respirations: 32 breaths/minute

Blood pressure: 168/96 mmHg

Oxygen saturation: 88% on room air

1305

Vital signs

Temperature 99.3° F (37.4℃)

Heart rate: 136 beats/minute

Respirations: 42 breaths/minute

Blood pressure: 168/94 mmHg

Oxygen saturation: 85% on room air

Pain: 4 out of 10 on the numeric pain scale

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway. The client reports the pain and shortness of breath started two hours ago, at which time he went inside to rest but the pain did not subside.

Client reports a medical history of hypertension, hyperlipidemia, and total knee replacement three years ago. Clients denies any smoking history, but reports drinking 3-4 mixed alcoholic drinks each night.

Medications: metoprolol 100mg orally once per day, aspirin 81mg orally once per day, and atorvastatin 40mg orally once per day.

Focused client assessment completed. Client is oriented to person, place, time, and situation. Respirations are equal and labored. Lung sounds are clear bilaterally on auscultation. Client’s skin is diaphoretic and pale. S1 and S2 auscultated. Radial and pedal pulses palpable and 2+. Client endorses pain 6/10 in left chest and left shoulder. Client denies any recent cough, fever, or respiratory illness.

Chest x-ray: Negative; No evidence of infiltrates, pneumothorax, or pneumonia

Electrocardiogram: Heart rate 112 beats per minute, regular rhythm, p-wave 0.16 seconds, QRS complex 0.08 seconds, no ST elevation noted

Complete Blood Count, Comprehensive Metabolic Panel, Troponin-I, 12-lead Electrocardiogram (EKG), chest x-ray, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol

NPO except medications

Aspirin 325 mg chewable tablet NOW

Sublingual nitroglycerin 0.3mg q5min x 3 doses as needed for chest pain 

Oxygen per nasal cannula; titrate to keep oxygen saturation > 94%

Morphine 2mg IV NOW 

Enoxaparin 1 mg/kg subcutaneous every 12 hours

Vital Signs: Temperature 37.1 ℃, HR 118 bpm, BP 164/90 mmHg, RR 22 bpm, O2 saturation 89% on room air.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway. The client reports the pain and shortness of breath started two hours ago, at which time he went inside to rest but the pain did not subside.

Client reports a medical history of hypertension, hyperlipidemia, and total knee replacement three years ago. Clients denies any smoking history, but reports drinking 3-4 mixed alcoholic drinks each night.

Medications: metoprolol 100mg orally once per day, aspirin 81mg orally once per day, and atorvastatin 40mg orally once per day.

Focused client assessment completed. Client is oriented to person, place, time, and situation. Respirations are equal and labored. Lung sounds are clear bilaterally on auscultation. Client’s skin is diaphoretic and pale. S1 and S2 auscultated. Radial and pedal pulses palpable and 2+. Client endorses pain 6/10 in left chest and left shoulder. Client denies any recent cough, fever, or respiratory illness.

Chest x-ray: Negative; No evidence of infiltrates, pneumothorax, or pneumonia

Electrocardiogram: Heart rate 112 beats per minute, regular rhythm, p-wave 0.16 seconds, QRS complex 0.08 seconds, no ST elevation noted

Complete Blood Count, Comprehensive Metabolic Panel, Troponin-I, 12-lead Electrocardiogram (EKG), chest x-ray, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol

Vital Signs: Temperature 37.1 ℃, HR 118 bpm, BP 164/90 mmHg, RR 22 bpm, O2 saturation 89% on room air.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway. The client reports the pain and shortness of breath started two hours ago, at which time he went inside to rest but the pain did not subside.

Client reports a medical history of hypertension, hyperlipidemia, and total knee replacement three years ago. Clients denies any smoking history, but reports drinking 3-4 mixed alcoholic drinks each night.

Medications: metoprolol 100mg orally once per day, aspirin 81mg orally once per day, and atorvastatin 40mg orally once per day.

Focused client assessment completed. Client is oriented to person, place, time, and situation. Respirations are equal and labored. Lung sounds are clear bilaterally on auscultation. Client’s skin is diaphoretic and pale. S1 and S2 auscultated. Radial and pedal pulses palpable and 2+. Client endorses pain 6/10 in left chest and left shoulder. Client denies any recent cough, fever, or respiratory illness.

Chest x-ray: Negative; No evidence of infiltrates, pneumothorax, or pneumonia

Electrocardiogram: Heart rate 112 beats per minute, regular rhythm, p-wave 0.16 seconds, QRS complex 0.08 seconds, no ST elevation noted

Complete Blood Count, Comprehensive Metabolic Panel, Troponin-I, 12-lead Electrocardiogram (EKG), chest x-ray, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol

Vital Signs: Temperature 37.1 ℃, HR 118 bpm, BP 164/90 mmHg, RR 22 bpm, O2 saturation 89% on room air.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway. The client reports the pain and shortness of breath started two hours ago, at which time he went inside to rest but the pain did not subside.

Client reports a medical history of hypertension, hyperlipidemia, and total knee replacement three years ago. Clients denies any smoking history, but reports drinking 3-4 mixed alcoholic drinks each night.

Medications: metoprolol 100mg orally once per day, aspirin 81mg orally once per day, and atorvastatin 40mg orally once per day.

Focused client assessment completed. Client is oriented to person, place, time, and situation. Respirations are equal and labored. Lung sounds are clear bilaterally on auscultation. Client’s skin is diaphoretic and pale. S1 and S2 auscultated. Radial and pedal pulses palpable and 2+. Client endorses pain 6/10 in left chest and left shoulder. Client denies any recent cough, fever, or respiratory illness.

Vital Signs: Temperature 37.1 ℃, HR 118 bpm, BP 164/90 mmHg, RR 22 bpm, O2 saturation 89% on room air.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway.

The client is a 64-year-old male that arrived in the Emergency Department via ambulance with complaints of shortness of breath and chest pain while washing his car in the driveway. The client reports the pain and shortness of breath started two hours ago, at which time he went inside to rest but the pain did not subside.

Client reports a medical history of hypertension, hyperlipidemia, and total knee replacement three years ago. Clients denies any smoking history, but reports drinking 3-4 mixed alcoholic drinks each night.

Medications: metoprolol 100mg orally once per day, aspirin 81mg orally once per day, and atorvastatin 40mg orally once per day.

Focused client assessment completed. Client is oriented to person, place, time, and situation. Respirations are equal and labored. Lung sounds are clear bilaterally on auscultation. Client’s skin is diaphoretic and pale. S1 and S2 auscultated. Radial and pedal pulses palpable and 2+. Client endorses pain 6/10 in left chest and left shoulder. Client denies any recent cough, fever, or respiratory illness.

Chest x-ray: Negative; No evidence of infiltrates, pneumothorax, or pneumonia

Electrocardiogram: Heart rate 112 beats per minute, regular rhythm, p-wave 0.16 seconds, QRS complex 0.08 seconds, no ST elevation noted

Complete Blood Count, Comprehensive Metabolic Panel, Troponin-I, 12-lead Electrocardiogram (EKG), chest x-ray, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol

Vital Signs: Temperature 37.1 ℃, HR 118 bpm, BP 164/90 mmHg, RR 22 bpm, O2 saturation 89% on room air.

The client is a 52-year-old male that arrived at the Emergency Department

The client is a 52-year-old male that arrived at the Emergency Department accompanied by his wife 12 hours after he completed a vigorous exercise regimen in the midday heat followed by a dinner of hamburgers, French fries, and beers with his longtime friend who was in town visiting. The client states that he has been experiencing increasing shortness of breath, lethargy, dizziness, and muscle twitching. He also reports very dark yellow urine.

Client reports a medical history of hypertension, early onset type II diabetes, coronary artery disease, obesity, and recently quit smoking after 25 years. 

Medications: lisinopril 40 mg orally once per day, aspirin 81 mg orally once per day, and naproxen 250 mg four times per day as needed.

Focused client assessment completed. Client is lethargic but is oriented to person, place, time, and situation. Client’s work of breathing is labored, even, with accessory muscles in use. Lungs are clear bilaterally on auscultation. S1 and S2 auscultated. Radial and pedal pulses palpable, alternating strength between normal and thready. Capillary refill greater than 3 seconds in lower extremities. Skin color pale, warm to touch in all extremities. Mucous membranes dry. Muscle strength graded as weak in the upper and lower extremities, equal bilaterally. Hyperreflexia appreciated in the upper extremities bilaterally. 

EKG: Sinus Tachycardia with peaked T waves and prolonged ST segment.

Complete Blood Count, Basic Metabolic Panel, Urinalysis, A12-lead Electrocardiogram, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol.

Administer 10 mL of a 10% calcium gluconate solution intravenously over 2 to 3 minutes

Inject 10 units of Regular Insulin intravenously followed by 25 g of 50% dextrose intravenously now

Albuterol 20 mg nebulized solution now

Infuse D5W with 3 ampules of bicarbonate intravenously at 125 mL/hr

Vital Signs: Temperature 37.4 ℃, HR 122, BP 90/56, RR 32, O2 saturation 95% on room air.

The client is a 52-year-old male that arrived at the Emergency Department

The client is a 52-year-old male that arrived at the Emergency Department accompanied by his wife 12 hours after he completed a vigorous exercise regimen in the midday heat followed by a dinner of hamburgers, French fries, and beers with his longtime friend who was in town visiting. The client states that he has been experiencing increasing shortness of breath, lethargy, dizziness, and muscle twitching. He also reports very dark yellow urine.

Client reports a medical history of hypertension, early onset type II diabetes, coronary artery disease, obesity, and recently quit smoking after 25 years. 

Medications: lisinopril 40 mg orally once per day, aspirin 81 mg orally once per day, and naproxen 250 mg four times per day as needed.

Focused client assessment completed. Client is lethargic but is oriented to person, place, time, and situation. Client’s work of breathing is labored, even, with accessory muscles in use. Lungs are clear bilaterally on auscultation. S1 and S2 auscultated. Radial and pedal pulses palpable, alternating strength between normal and thready. Capillary refill greater than 3 seconds in lower extremities. Skin color pale, warm to touch in all extremities. Mucous membranes dry. Muscle strength graded as weak in the upper and lower extremities, equal bilaterally. Hyperreflexia appreciated in the upper extremities bilaterally. 

EKG: Sinus Tachycardia with peaked T waves and prolonged ST segment.

Complete Blood Count, Basic Metabolic Panel, Urinalysis, A12-lead Electrocardiogram, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol.

Vital Signs: Temperature 37.4 ℃, HR 122, BP 90/56, RR 32, O2 saturation 95% on room air.

The client is a 52-year-old male that arrived at the Emergency Department

The client is a 52-year-old male that arrived at the Emergency Department accompanied by his wife 12 hours after he completed a vigorous exercise regimen in the midday heat followed by a dinner of hamburgers, French fries, and beers with his longtime friend who was in town visiting. The client states that he has been experiencing increasing shortness of breath, lethargy, dizziness, and muscle twitching. He also reports very dark yellow urine.

Client reports a medical history of hypertension, early onset type II diabetes, coronary artery disease, obesity, and recently quit smoking after 25 years. 

Medications: lisinopril 40 mg orally once per day, aspirin 81 mg orally once per day, and naproxen 250 mg four times per day as needed.

Focused client assessment completed. Client is lethargic but is oriented to person, place, time, and situation. Client’s work of breathing is labored, even, with accessory muscles in use. Lungs are clear bilaterally on auscultation. S1 and S2 auscultated. Radial and pedal pulses palpable, alternating strength between normal and thready. Capillary refill greater than 3 seconds in lower extremities. Skin color pale, warm to touch in all extremities. Mucous membranes dry. Muscle strength graded as weak in the upper and lower extremities, equal bilaterally. Hyperreflexia appreciated in the upper extremities bilaterally. 

EKG: Sinus Tachycardia with peaked T waves and prolonged ST segment.

Complete Blood Count, Basic Metabolic Panel, Urinalysis, A12-lead Electrocardiogram, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol.

Vital Signs: Temperature 37.4 ℃, HR 122, BP 90/56, RR 32, O2 saturation 95% on room air.

The client is a 52-year-old male that arrived at the Emergency Department

The client is a 52-year-old male that arrived at the Emergency Department accompanied by his wife 12 hours after he completed a vigorous exercise regimen in the midday heat followed by a dinner of hamburgers, French fries, and beers with his longtime friend who was in town visiting. The client states that he has been experiencing increasing shortness of breath, lethargy, dizziness, and muscle twitching. He also reports very dark yellow urine.

Client reports a medical history of hypertension, early onset type II diabetes, coronary artery disease, obesity, and recently quit smoking after 25 years. 

Medications: lisinopril 40 mg orally once per day, aspirin 81 mg orally once per day, and naproxen 250 mg four times per day as needed.

Focused client assessment completed. Client is lethargic but is oriented to person, place, time, and situation. Client’s work of breathing is labored, even, with accessory muscles in use. Lungs are clear bilaterally on auscultation. S1 and S2 auscultated. Radial and pedal pulses palpable, alternating strength between normal and thready. Capillary refill greater than 3 seconds in lower extremities. Skin color pale, warm to touch in all extremities. Mucous membranes dry. Muscle strength graded as weak in the upper and lower extremities, equal bilaterally. Hyperreflexia appreciated in the upper extremities bilaterally. 

EKG: Sinus Tachycardia with peaked T waves and prolonged ST segment.

Complete Blood Count, Basic Metabolic Panel, Urinalysis, A12-lead Electrocardiogram, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol.

Vital Signs: Temperature 37.4 ℃, HR 122, BP 90/56, RR 32, O2 saturation 95% on room air.

The client is a 52-year-old male that arrived at the Emergency Department

The client is a 52-year-old male that arrived at the Emergency Department accompanied by his wife 12 hours after he completed a vigorous exercise regimen in the midday heat followed by a dinner of hamburgers, French fries, and beers with his longtime friend who was in town visiting. The client states that he has been experiencing increasing shortness of breath, lethargy, dizziness, and muscle twitching. He also reports very dark yellow urine.

Client reports a medical history of hypertension, early onset type II diabetes, coronary artery disease, obesity, and recently quit smoking after 25 years. 

Medications: lisinopril 40 mg orally once per day, aspirin 81 mg orally once per day, and naproxen 250 mg four times per day as needed.

Focused client assessment completed. Client is lethargic but is oriented to person, place, time, and situation. Client’s work of breathing is labored, even, with accessory muscles in use. Lungs are clear bilaterally on auscultation. S1 and S2 auscultated. Radial and pedal pulses palpable, alternating strength between normal and thready. Capillary refill greater than 3 seconds in lower extremities. Skin color pale, warm to touch in all extremities. Mucous membranes dry. Muscle strength graded as weak in the upper and lower extremities, equal bilaterally. Hyperreflexia appreciated in the upper extremities bilaterally. 

Complete Blood Count, Basic Metabolic Panel, Urinalysis, A12-lead Electrocardiogram, insert intravenous line, vital signs per protocol, cardiac monitoring per protocol.

Vital Signs: Temperature 37.4 ℃, HR 122, BP 90/56, RR 32, O2 saturation 95% on room air.

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

0820: This RN performs a focused assessment of the client including rechecking blood glucose.

0825: Administered 4oz juice, graham crackers, and peanut butter.  Notified MD of use of hypoglycemia protocol use.  Will follow up after 15 minute blood glucose recheck.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0820:

Integumentary- intact, diaphoresis

Cardio- audible S1S2

Neuro- oriented to person and place, unable to state day or time, +gag

GI- hyperactive bowel sounds x4 quadrants

Musculoskeletal- generalized weakness

0840:

Integumentary- intact

Cardio- audible S1S2

Neuro- oriented to person, place, time, and situation

GI- hyperactive bowel sounds x4 quadrants

0800 Blood Glucose: 56 mg/dL

0820: Blood glucose: 54mg/dL

0845: Blood glucose: 84mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

0820:

HR 96bpm

RR 20

O2 94%

0845:

T 97.6F axillary
HR 84bpm
BP 116/72
RR 18

O2 95%

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

0820: This RN performs a focused assessment of the client including rechecking blood glucose.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0820:

Integumentary- intact, diaphoresis

Cardio- audible S1S2

Neuro- oriented to person and place, unable to state day or time, +gag

GI- hyperactive bowel sounds x4 quadrants

Musculoskeletal- generalized weakness

0800 Blood Glucose: 56 mg/dL

0820: Blood glucose: 54mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

For hypoglycemia:

Give 50% Dextrose, 25gm, (50 mL) intravenous push, ONCE

Give Glucagon 1mg intramuscularly ONCE

Give 4oz (120mL) of juice, if client is able to swallow and is NOT NPO

Give 50% Dextrose, 12.5gm, (25 ml) IV push, ONCE

Send serum glucose level STAT

Recheck bedside glucose every 15 minutes after treatment is given

Run 10% dextrose infusion (500ml) at 40 ml/hr

Notify Provider

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

0820:

HR 96bpm

RR 20

O2 94%

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

0820: This RN performs a focused assessment of the client including rechecking blood glucose.

0825: Administered 4oz juice, graham crackers, and peanut butter.  Notified MD of use of hypoglycemia protocol use.  Will follow up after 15 minute blood glucose recheck.

0850: Called MD with updated blood glucose, vitals, and improvement in mental status.  Breakfast tray arrived.  Orders received to hold all insulin lispro and recheck one hour postprandial blood glucose.  Will notify MD of result.  Will continue to monitor client.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0820:

Integumentary- intact, diaphoresis

Cardio- audible S1S2

Neuro- oriented to person and place, unable to state day or time, +gag

GI- hyperactive bowel sounds x4 quadrants

Musculoskeletal- generalized weakness

0840:

Integumentary- intact

Cardio- audible S1S2

Neuro- oriented to person, place, time, and situation

GI- hyperactive bowel sounds x4 quadrants

0800 Blood Glucose: 56 mg/dL

0820: Blood glucose: 54mg/dL

0845: Blood glucose: 84mg/dL

0945: Blood glucose: 212mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

0820:

HR 96bpm

RR 20

O2 94%

0845:

T 97.6F axillary
HR 84bpm
BP 116/72
RR 18O2 95%

0900: Intake 360mL coffee with creamer, scrambled eggs, ham, 2 pieces of toast with jelly

0930: Output: 1 urine occurrence, 1 stool occurrence

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

0820: This RN performs a focused assessment of the client including rechecking blood glucose.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0820:

Integumentary- intact, diaphoresis

Cardio- audible S1S2

Neuro- oriented to person and place, unable to state day or time, +gag

GI- hyperactive bowel sounds x4 quadrants

Musculoskeletal- generalized weakness

0800 Blood Glucose: 56 mg/dL

0820: Blood glucose: 54mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

0820:

HR 96bpm

RR 20

O2 94%

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0800 Blood Glucose: 56 mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

68 year old female client admitted yesterday for observation following an episode of syncope at home

0815: This RN notified by unlicensed assistive personnel (UAP) of client 0800 vital signs and blood glucose reading.  UAP stated client was angry because breakfast tray had not yet arrived despite being drowsier than usual.  UAP also reported increased assistance needed with ambulating to bathroom.

68 year old female client admitted yesterday for observation following an episode of syncope at home

Past Medical History: Type I diabetes mellitus and peripheral neuropathy

0800 Blood Glucose: 56 mg/dL

glargine (Lantus) 15 units SC QHS

insulin lispro (Humalog) 4 units SC AC and HS

insulin lispro (Humalog) 1 unit: 15g carbohydrates SC AC and HS

gabapentin (Neurontin) 300mg PO BID

0800

T 98.8F oral
HR 90bpm
BP 110/68
RR 20

O2 93%

Output: 1 urine occurrence

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home.

0300 Stroke Triage RN Notes

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home. His wife states he awakened in the night with slurred speech, severe headache, nausea and vomiting, twitching (described by spouse), and a change in the level of consciousness from alert and oriented to a Glasgow coma scale of 14. Finger stick glucose 109. Lungs clear with coarse breath sounds. S1, S2 present on cardiac auscultation. Abdomen soft, with positive bowel sounds in all 4 quadrants. Positive peripheral pulses, negative edema. The client is pale, skin warm and dry. 

Past Medical History

Hypertension for ten years

Hyperlipidemia

Obesity

Sleep apnea

Recently started on coumadin for Atrial Fibrillation

No trauma

Intracerebral hemorrhage

No Known Drug allergies

Social

Drinks 1-2 alcoholic drinks daily

Smokes 2 packs of cigarettes per day x 20 years

Client’s Home Meds

Metoprolol 100 mg Extended Release daily

Hydrochlorothiazide 25 mg every morning

Atorvastatin 40 mg every evening

Coumadin 10 mg every evening

Home medical equipment

Continuous Positive Pressure Airway machine 

Physical Assessment

Neurological: Glasgow coma scale 14

Respiratory: lungs clear bilaterally on auscultation

Cardiovascular:  S1 and S 2 auscultated

Gastrointestinal: bowel sounds positive in all 4 quadrants

Genito Urinary:-belly over bladder area soft, not distended.

Integumentary: pale, skin warm and dry

BP 190/110 mmHg, HR- 115 BPM, RR 30 per minute, T 98.8 F. Pulse Oximetry SAO2 91%

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home.

0300 Stroke Triage RN Notes

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home. His wife states he awakened in the night with slurred speech, severe headache, nausea and vomiting, twitching (described by spouse), and a change in the level of consciousness from alert and oriented to a Glasgow coma scale of 14. Finger stick glucose 109. Lungs clear with coarse breath sounds. S1, S2 present on cardiac auscultation. Abdomen soft, with positive bowel sounds in all 4 quadrants. Positive peripheral pulses, negative edema. The client is pale, skin warm and dry. 

Past Medical History

Hypertension for ten years

Hyperlipidemia

Obesity

Sleep apnea

Recently started on coumadin for Atrial Fibrillation

No trauma

Intracerebral hemorrhage

No Known Drug allergies

Social

Drinks 1-2 alcoholic drinks daily

Smokes 2 packs of cigarettes per day x 20 years

Client’s Home Meds

Metoprolol 100 mg Extended Release daily

Hydrochlorothiazide 25 mg every morning

Atorvastatin 40 mg every evening

Coumadin 10 mg every evening

Home medical equipment

Continuous Positive Pressure Airway machine 

Physical Assessment

Neurological: Glasgow coma scale 14

Respiratory: lungs clear bilaterally on auscultation

Cardiovascular:  S1 and S 2 auscultated

Gastrointestinal: bowel sounds positive in all 4 quadrants

Genito Urinary:-belly over bladder area soft, not distended.

Integumentary: pale, skin warm and dry

Start IV

CBC

Electrolytes

Calcium

Albumin

ALT

AST

Alkaline Phosphorus

Total Bilirubin

Troponin

TSH

T3, T 4

Cholesterol 

C-reactive Protein test and blood protein test

PT

INR

aPTT

Type and Screen

CT

EKG

CXR

O2 to maintain saturation at 92%

BP 190/100 mmHg, HR- 100 BPM, RR 18 per minute, T 98.8 F. Pulse Oximetry SAO2 98%

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home.

0300 Stroke Triage RN Notes

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home. His wife states he awakened in the night with slurred speech, severe headache, nausea and vomiting, twitching (described by spouse), and a change in the level of consciousness from alert and oriented to a Glasgow coma scale of 14. Finger stick glucose 109. Lungs clear with coarse breath sounds. S1, S2 present on cardiac auscultation. Abdomen soft, with positive bowel sounds in all 4 quadrants. Positive peripheral pulses, negative edema. The client is pale, skin warm and dry. 

Past Medical History

Hypertension for ten years

Hyperlipidemia

Obesity

Sleep apnea

Recently started on coumadin for Atrial Fibrillation

No trauma

Intracerebral hemorrhage

No Known Drug allergies

Social

Drinks 1-2 alcoholic drinks daily

Smokes 2 packs of cigarettes per day x 20 years

Client’s Home Meds

Metoprolol 100 mg Extended Release daily

Hydrochlorothiazide 25 mg every morning

Atorvastatin 40 mg every evening

Coumadin 10 mg every evening

Home medical equipment

Continuous Positive Pressure Airway machine 

Physical Assessment

Neurological: Glasgow coma scale 14

Respiratory: lungs clear bilaterally on auscultation

Cardiovascular:  S1 and S 2 auscultated

Gastrointestinal: bowel sounds positive in all 4 quadrants

Genito Urinary:-belly over bladder area soft, not distended.

Integumentary: pale, skin warm and dry

1. Vitamin K 5 mg IV push
2. IV Labetalol 10 mg over 1-2 minutes.
3. Nicardipine 5mg per hour IV infusion initially. Titrate to Systolic Blood Pressure of 160. Increase dosage 2.5 mg/hour every 5 minutes to a maximum of 15 mg/hour
4. Fresh Frozen plasma 2 units 12-15 ml/kg

BP 190/105 mmHg, HR- 115 BPM, RR 32 per minute, T 98.8 F. Pulse Oximetry SAO2 91%

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home.

0300 Stroke Triage RN Notes

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home. His wife states he awakened in the night with slurred speech, severe headache, nausea and vomiting, twitching (described by spouse), and a change in the level of consciousness from alert and oriented to a Glasgow coma scale of 14. Finger stick glucose 109. Lungs clear with coarse breath sounds. S1, S2 present on cardiac auscultation. Abdomen soft, with positive bowel sounds in all 4 quadrants. Positive peripheral pulses, negative edema. The client is pale, skin warm and dry. 

0315 Primary RN Notes

The client is lying on a stretcher with the head of the bed at a 30-degree angle. Oxygen was placed at 2 liters per nasal cannula due to oxygen saturation at 91%. Respirations more shallow. Glasgow coma scale 14, lethargic, slurred speech, restless. Moving only right side of the body.

Past Medical History

Hypertension for ten years

Hyperlipidemia

Obesity

Sleep apnea

Recently started on coumadin for Atrial Fibrillation

No trauma

Intracerebral hemorrhage

No Known Drug allergies

Social

Drinks 1-2 alcoholic drinks daily

Smokes 2 packs of cigarettes per day x 20 years

Client’s Home Meds

Metoprolol 100 mg Extended Release daily

Hydrochlorothiazide 25 mg every morning

Atorvastatin 40 mg every evening

Coumadin 10 mg every evening

Home medical equipment

Continuous Positive Pressure Airway machine 

Physical Assessment

Neurological: Glasgow coma scale 14

Respiratory: lungs clear bilaterally on auscultation

Cardiovascular:  S1 and S 2 auscultated

Gastrointestinal: bowel sounds positive in all 4 quadrants

Genito Urinary:-belly over bladder area soft, not distended.

Integumentary: pale, skin warm and dry

BP 190/105 mmHg, HR- 115 BPM, RR 32 per minute, T 98.8 F. Pulse Oximetry SAO2 91%

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home.

0300 Stroke Triage RN Notes

The client is a 77-year-old male who arrived to the Emergency Department via EMS due to a 911 call to his home. His wife states he awakened in the night with slurred speech, severe headache, nausea and vomiting, twitching (described by spouse), and a change in the level of consciousness from alert and oriented to a Glasgow coma scale of 14. Finger stick glucose 109. Lungs clear with coarse breath sounds. S1, S2 present on cardiac auscultation. Abdomen soft, with positive bowel sounds in all 4 quadrants. Positive peripheral pulses, negative edema. The client is pale, skin warm and dry. 

Past Medical History

Hypertension for ten years

Hyperlipidemia

Obesity

Sleep apnea

Recently started on coumadin for Atrial Fibrillation

No trauma

Intracerebral hemorrhage

No Known Drug allergies

Social

Drinks 1-2 alcoholic drinks daily

Smokes 2 packs of cigarettes per day x 20 years

Client’s Home Meds

Metoprolol 100 mg Extended Release daily

Hydrochlorothiazide 25 mg every morning

Atorvastatin 40 mg every evening

Coumadin 10 mg every evening

Home medical equipment

Continuous Positive Pressure Airway machine 

Physical Assessment

Neurological: Glasgow coma scale 14

Respiratory: lungs clear bilaterally on auscultation

Cardiovascular:  S1 and S 2 auscultated

Gastrointestinal: bowel sounds positive in all 4 quadrants

Genito Urinary:-belly over bladder area soft, not distended.

Integumentary: pale, skin warm and dry

Start IV

CBC

Electrolytes

Calcium

Albumin

ALT

AST

Alkaline Phosphorus

Total Bilirubin

Troponin

TSH

T3, T 4

Cholesterol 

C-reactive Protein test and blood protein test

PT

INR

aPTT

Type and Screen

CT

EKG

CXR

O2 to maintain saturation at 92%

BP 190/100 mmHg, HR- 100 BPM, RR 18 per minute, T 98.8 F. Pulse Oximetry SAO2 98%

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Pulse oximetry

Oxygen at 2L/min to maintain SPO2 at 90%,

Complete blood count

Comprehensive metabolic panel

Arterial blood gases

Creatinine kinase

Troponin I

Brain natriuretic peptide

Electrocardiogram

Chest X Ray

Sputum culture

Chest Physiotherapy per Respiratory Therapy Protocol

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi. 

1030 ED Primary RN Notes

Client’s vital signs reassessed. Breathing slightly less labored since Oxygen placed.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Aterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Fenoterol 100 micrograms every 6 hours via nebulizer

Prednisone 40 mg orally daily x 5 days.

Temperature 98.3 Fahrenheit, heart rate  100 beats per minute, respiratory rate 24, Blood Pressure 110/68,  and Oxygen saturation 89% on 2L/nasal cannula.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.

1000 ED Triage RN Notes

The client is a 55 year-old female who presented to the emergency department complaining of being unable to get her breath. Client states she has not felt well for the last two days, describing shortness of breath, fatigue and low energy.  Six months ago she had similar symptoms and was told that she had chronic obstructive pulmonary disease.  She reports shortness of breath at rest, being forgetful, feeling chilly and needing blankets

Lungs bilateral coarse breath sounds with bibasilar rhonchi. Positive peripheral pulses, negative edema.

1010 ED Primary RN Notes

The client is lying on a stretcher, head of bed elevated at 45 degree angle. Oxygen plated at 2 liters per nasal cannula due to O2 saturation of 88% and orders to maintain O2 at 90%. Respirations shallow, labored. Complains of being cold, warm blankets placed. Lungs bilaterally coarse with bibasilar rhonchi.

Past Medical History 

Chronic Obstructive Pulmonary Disease

Sleep apnea

No Known Drug Allergies

Social

Smokes 3 packs of cigarettes per day x 30 years

Client’s Home Meds

Fluticasone-vilanterol 100-25 mcg inhaled daily

Hydrochlorothiazide 25 mg by mouth daily

Albuterol -ipratropium inhaled every 4 hours prn

.

Home medical equipment-Bipap Ventilatory Support at home

Physical Assessment

Neurological: Alert, oriented to person and place, not date or month

Respiratory: Mild end expiratory wheezing, past FEV1FVC 0.8. Increased work of breathing, cough, use of accessory muscles, crackles bilaterally, shallow respirations, hyperresonance on percussion, pale lips and nail beds cyanotic.

Cardiovascular:  S1 and S 2 auscultated, tachycardic rhythm

Gastrointestinal: Abdomen soft, with positive bowel sounds all 4 quadrants

Genito Urinary:

Integumentary: pale, warm, dry, nail beds pale, bluish tinted

Hemoglobin 13

Hematocrit-40.5

White Blood Count 4.5 billion cells/L

Na-140

K-4.5

Cl-100

Calcium 9.5

Arterial blood gases pH 7.491, PCOD 27.6, POq 66.6 HCO3 20.6, Oxygen saturation 88% on room air. 

Creatinine kinase normal

Troponin I-negative

Brain natriuretic peptide 85pg/ml

Electrocardiogram-sinus tachycardia, no ST or T wave changes

Chest X Ray-bibasilar airway disease. Small bilateral pleural effusions. 

Sputum culture obtained

Temperature 99.3 Fahrenheit, heart rate 110 beats per minute, respiratory rate 28, Blood Pressure 104/54, weight 100 Kilograms, BMI 39.2, and Oxygen saturation 88% on room air.

This RN performed an assessment. Patient is G1P0 30 weeks gestation. Patient with complaint of headache and nerve pain to leg. Vital signs being taken by medical assistant.

1600: This RN performed an assessment.  Patient is G1P0 30 weeks gestation.  Patient with complaint of headache and nerve pain to leg.  Vital signs being taken by medical assistant.  Weight being taken by medical assistant.  Urine specimen sent to lab.

Head to Toe Assessment 1600 within defined limits except:
    2+ edema to hands and feet

     complaint of headache 5/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     epigastric pain, intermittent, worse after eating

     fatigue

Urinalysis

bacteria – absent

leukocytes <5

nitrite – absent

blood <5

epithelial cells <5

ketones – absent

bilirubin – absent

protein 30mg/dL

glucose – normal

Vital Signs

T 99.2F oral

HR 74bpm

BP 146/94

RR 18

O2 95%

Weight 

214lbs (8% weight gain from last visit)

This RN performed an assessment. Patient is G1P0 30 weeks gestation. Patient with complaint of headache and nerve pain to leg. Vital signs being taken by medical assistant.

1600: This RN performed an assessment.  Patient is G1P0 30 weeks gestation.  Patient with complaint of headache and nerve pain to leg.  Vital signs being taken by medical assistant.  Weight being taken by medical assistant.  Urine specimen sent to lab.

Head to Toe Assessment 1600 within defined limits except:
    2+ edema to hands and feet

     complaint of headache 5/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     epigastric pain, intermittent, worse after eating

     fatigue

Urinalysis

bacteria – absent

leukocytes <5

nitrite – absent

blood <5

epithelial cells <5

ketones – absent

bilirubin – absent

protein 30mg/dL

glucose – normal

Vital Signs

T 99.2F oral

HR 74bpm

BP 146/94

RR 18

O2 95%

Weight 

214lbs (8% weight gain from last visit)

This RN performed an assessment. Patient is G1P0 30 weeks gestation. Patient with complaint of headache and nerve pain to leg. Vital signs being taken by medical assistant.

1600: This RN performed an assessment.  Patient is G1P0 30 weeks gestation.  Patient with complaint of headache and nerve pain to leg.  Vital signs being taken by medical assistant.  Weight being taken by medical assistant.  Urine specimen sent to lab.

Head to Toe Assessment 1600 within defined limits except:
    2+ edema to hands and feet

     complaint of headache 5/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     epigastric pain, intermittent, worse after eating

     fatigue

Urinalysis

bacteria – absent

leukocytes <5

nitrite – absent

blood <5

epithelial cells <5

ketones – absent

bilirubin – absent

protein 30mg/dL

glucose – normal

Vital Signs

T 99.2F oral

HR 74bpm

BP 146/94

RR 18

O2 95%

Weight 

214lbs (8% weight gain from last visit)

This RN performed an assessment. Patient is G1P0 30 weeks gestation. Patient with complaint of headache and nerve pain to leg. Vital signs being taken by medical assistant.

1600: This RN performed an assessment.  Patient is G1P0 30 weeks gestation.  Patient with complaint of headache and nerve pain to leg.  Vital signs being taken by medical assistant.  Weight being taken by medical assistant.  Urine specimen sent to lab.

1630: Orders received.  Healthcare provider considering admission vs. home on bedrest.

1700: Magnesium sulfate infusion complete, rechecked HR/BP, patient resting in lateral recumbent position

Head to Toe Assessment 1600 within defined limits except:
    2+ edema to hands and feet

     complaint of headache 5/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     epigastric pain, intermittent, worse after eating

     fatigue

Head to Toe Assessment 1700 within defined limits except:

     2+ edema in hands and feet

     complaint of headache 2/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     fatigue

     blurry vision

Urinalysis

bacteria – absent

leukocytes <5

nitrite – absent

blood <5

epithelial cells <5

ketones – absent

bilirubin – absent

protein 30mg/dL

glucose – normal

magnesium sulfate 4 g IV over 30 min

monitor BP Q15 minutes

bedrest

acetaminophen 650mg PO Q6hr PRN

calcium carbonate 1000mg PO Q6hr PRN

fundal height measurement

Vital Signs

1600- 

T 99.2F oral

HR 74bpm

BP 146/94

RR 18

O2 95%

1630-

HR 80

BP 152/98

1700-

HR 70

BP 140/88

Weight 

214lbs (8% weight gain from last visit)

Fundal Height

30cm

This RN performed an assessment. Patient is G1P0 30 weeks gestation. Patient with complaint of headache and nerve pain to leg. Vital signs being taken by medical assistant.

1600: This RN performed an assessment.  Patient is G1P0 30 weeks gestation.  Patient with complaint of headache and nerve pain to leg.  Vital signs being taken by medical assistant.  Weight being taken by medical assistant.  Urine specimen sent to lab.

Head to Toe Assessment 1600 within defined limits except:
    2+ edema to hands and feet

     complaint of headache 5/10 on numbers pain scale

     nerve pain to the right hip radiating down the leg 3/10

     epigastric pain, intermittent, worse after eating

     fatigue

Urinalysis

bacteria – absent

leukocytes <5

nitrite – absent

blood <5

epithelial cells <5

ketones – absent

bilirubin – absent

protein 30mg/dL

glucose – normal

Vital Signs

T 99.2F oral

HR 74bpm

BP 146/94

RR 18

O2 95%

Weight 

214lbs (8% weight gain from last visit)

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago.

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago. Client presentation with spontaneous rupture of membranes but was unable to progress after a prolonged first stage of labor. The client received oxytocin for induction for 23 hours. The pregnancy was uncomplicated except for a diagnosis of gestational diabetes for the mother.

Past Medical History

Client’s past medical history includes uterine fibroids and depression. Client’s BMI is 32.  Client is taking citalopram 20 mg daily for depression.

Vital signs prior to transfer:

T 98.7F, P 84, RR 16, BP 126/76, SpO2 99% Room Air

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago.

Transfer note: Client arrives to postpartum unit and is oriented to the room. Client is accompanied by partner and infant.  Client complains of feeling a little “dizzy.” Physical assessment reveals large, boggy uterus. Peri pad appears saturated with blood containing several clots. Client states she changed peri pad just a “few minutes ago,” prior to coming to the unit. IV site is clean, dry. Client rates pain at 3/10 in the perineal area. Grade I perineal laceration has no visible bleeding or hematoma at this time.

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago. Client presentation with spontaneous rupture of membranes but was unable to progress after a prolonged first stage of labor. The client received oxytocin for induction for 23 hours. The pregnancy was uncomplicated except for a diagnosis of gestational diabetes for the mother.

Past Medical History

Client’s past medical history includes uterine fibroids and depression. Client’s BMI is 32.  Client is taking citalopram 20 mg daily for depression.

Labs collected prior to transfer to postpartum unit, after delivery:

Transfer orders:

• Regular diet
• H&H Q8H x 24 hours
• IV to saline lock
• Bathroom privileges with assistance
• Lactation consult in AM

Vital signs upon arrival to unit:

T 98.6F, P 86, RR 16, BP 124/72, SpO2 99% Room Air

Vital signs prior to transfer:

T 98.7F, P 84, RR 16, BP 126/76, SpO2 99% Room Air

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago.

Transfer note: Client arrives to postpartum unit and is oriented to the room. Client is accompanied by partner and infant.  Client complains of feeling a little “dizzy.” Physical assessment reveals large, boggy uterus. Peri pad appears saturated with blood containing several clots. Client states she changed peri pad just a “few minutes ago,” prior to coming to the unit. IV site is clean, dry. Client rates pain at 3/10 in the perineal area. Grade I perineal laceration has no visible bleeding or hematoma at this time.

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago. Client presentation with spontaneous rupture of membranes but was unable to progress after a prolonged first stage of labor. The client received oxytocin for induction for 23 hours. The pregnancy was uncomplicated except for a diagnosis of gestational diabetes for the mother.

Past Medical History

Client’s past medical history includes uterine fibroids and depression. Client’s BMI is 32.  Client is taking citalopram 20 mg daily for depression.

Labs collected prior to transfer to postpartum unit, after delivery:

Transfer orders:

• Regular diet
• H&H Q8H x 24 hours
• IV to saline lock
• Bathroom privileges with assistance
• Lactation consult in AM

Vital signs upon arrival to unit:

T 98.6F, P 86, RR 16, BP 124/72, SpO2 99% Room Air

Vital signs prior to transfer:

T 98.7F, P 84, RR 16, BP 126/76, SpO2 99% Room Air

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago.

Transfer note: Client arrives to postpartum unit and is oriented to the room. Client is accompanied by partner and infant.  Client complains of feeling a little “dizzy.” Physical assessment reveals large, boggy uterus. Peri pad appears saturated with blood containing several clots. Client states she changed peri pad just a “few minutes ago,” prior to coming to the unit. IV site is clean, dry. Client rates pain at 3/10 in the perineal area. Grade I perineal laceration has no visible bleeding or hematoma at this time.

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago. Client presentation with spontaneous rupture of membranes but was unable to progress after a prolonged first stage of labor. The client received oxytocin for induction for 23 hours. The pregnancy was uncomplicated except for a diagnosis of gestational diabetes for the mother.

Past Medical History

Client’s past medical history includes uterine fibroids and depression. Client’s BMI is 32.  Client is taking citalopram 20 mg daily for depression.

Labs collected prior to transfer to postpartum unit, after delivery:

Transfer orders:

• Regular diet
• H&H Q8H x 24 hours
• IV to saline lock
• Bathroom privileges with assistance
• Lactation consult in AM

Vital signs upon arrival to unit:

T 98.6F, P 86, RR 16, BP 124/72, SpO2 99% Room Air

Vital signs prior to transfer:

T 98.7F, P 84, RR 16, BP 126/76, SpO2 99% Room Air

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago.

Progress note: Provider orders initiated. Approximately 20 minutes after initiation of Oxytocin and fundal massage, uterus was noted to be firm. There is no steady perineal bleeding noted. Client reports dizziness is improving. Client reports pain 4/10 at perineal area. New peri pad applied to client to closely monitor bleeding. Provider updated on client’s current condition.

Transfer note: Client arrives to postpartum unit and is oriented to the room. Client is accompanied by partner and infant.  Client complains of feeling a little “dizzy.” Physical assessment reveals large, boggy uterus. Peri pad appears saturated with blood containing several clots. Client states she changed peri pad just a “few minutes ago,” prior to coming to the unit. IV site is clean, dry. Client rates pain at 3/10 in the perineal area. Grade I perineal laceration has no visible bleeding or hematoma at this time.

Client is a 31-year-old female, G1P1, who is being transferred to the postpartum unit following a vacuum-assisted vaginal delivery of a 39-week gestation singleton weighing 4,400 grams two hours ago. Client presentation with spontaneous rupture of membranes but was unable to progress after a prolonged first stage of labor. The client received oxytocin for induction for 23 hours. The pregnancy was uncomplicated except for a diagnosis of gestational diabetes for the mother.

Past Medical History

Client’s past medical history includes uterine fibroids and depression. Client’s BMI is 32.  Client is taking citalopram 20 mg daily for depression.

Most recent lab results:

Labs collected prior to transfer to postpartum unit, after delivery:

New orders:

• Perform fundal massage and reassess uterus q5min until firm
• H&H STAT
• Insert indwelling urinary catheter
• Vital signs q15 minutes
• IV NS 500 mL bolus
• Type and crossmatch 2 units RBCs
• Oxytocin 20 units in 1L NS: Infuse 10 units (500 mL) IV bolus over 30 minutes, followed by remaining 10 units over 3.5 hours (rate at 125 ml/hr)

Transfer orders:

• Regular diet
• H&H Q8H x 24 hours
• IV to saline lock
• Bathroom privileges with assistance
• Lactation consult in AM

Most recent vital signs:

T 98.9F, P 80, RR 18, BP 132/84, SpO2 98% Room Air

Current vital signs:

T 98.9F, P 90, RR 18, BP 120/72, SpO2 97% Room Air

Vital signs upon arrival to unit:

T 98.6F, P 86, RR 16, BP 124/72, SpO2 99% Room Air

Vital signs prior to transfer:

T 98.7F, P 84, RR 16, BP 126/76, SpO2 99% Room Air

This 2-year-old toddler was brought to the pediatric emergency department

This 2-year-old toddler was brought to the pediatric emergency department this evening by her parents. Parents report a 5-day history of diarrhea and estimate the child has had six to eight episodes of watery diarrhea and only two wet diapers today. Patient has a decreased appetite, but has been drinking well, including milk, water, and juice. Two other household members had diarrheal illnesses last week. There is no report of vomiting, fever, or recent changes to the diet.

This 2-year-old toddler was brought to the pediatric emergency department

1800

Nursing Assessment:

• Temperature: 98.3ºF (36.8ºC) 
• Heart rate: 156 beats/min
• Respiratory rate of 30 breaths/min
• Capillary refill approximately 3 to 4 seconds
• Buccal mucosa dry
• Eyes sunken
• Reduced skin turgor  
• Patient is crying and resisting examination

This 2-year-old toddler was brought to the pediatric emergency department this evening by her parents. Parents report a 5-day history of diarrhea and estimate the child has had six to eight episodes of watery diarrhea and only two wet diapers today. Patient has a decreased appetite, but has been drinking well, including milk, water, and juice. Two other household members had diarrheal illnesses last week. There is no report of vomiting, fever, or recent changes to the diet.

This 2-year-old toddler was brought to the pediatric emergency department

1800

Nursing Assessment:

• Temperature: 98.3ºF (36.8ºC) 
• Heart rate: 156 beats/min
• Respiratory rate of 30 breaths/min
• Capillary refill approximately 3 to 4 seconds
• Buccal mucosa dry
• Eyes sunken
• Reduced skin turgor  
• Patient is crying and resisting examination

This 2-year-old toddler was brought to the pediatric emergency department this evening by her parents. Parents report a 5-day history of diarrhea and estimate the child has had six to eight episodes of watery diarrhea and only two wet diapers today. Patient has a decreased appetite, but has been drinking well, including milk, water, and juice. Two other household members had diarrheal illnesses last week. There is no report of vomiting, fever, or recent changes to the diet.

1845:

• Monitor vital signs every 2 hours
• Assess perineal skin every 2 hours; keep clean and dry
• Begin oral rehydration therapy per protocol
• Assess stool losses and begin replacement therapy per protocol
• Advance to regular diet as tolerated

This 2-year-old toddler was brought to the pediatric emergency department

1800

Nursing Assessment:

• Temperature: 98.3ºF (36.8ºC) 
• Heart rate: 156 beats/min
• Respiratory rate of 30 breaths/min
• Capillary refill approximately 3 to 4 seconds
• Buccal mucosa dry
• Eyes sunken
• Reduced skin turgor  
• Patient is crying and resisting examination

This 2-year-old toddler was brought to the pediatric emergency department this evening by her parents. Parents report a 5-day history of diarrhea and estimate the child has had six to eight episodes of watery diarrhea and only two wet diapers today. Patient has a decreased appetite, but has been drinking well, including milk, water, and juice. Two other household members had diarrheal illnesses last week. There is no report of vomiting, fever, or recent changes to the diet.

This 2-year-old toddler was brought to the pediatric emergency department

1800

Nursing Assessment:

• Temperature: 98.3ºF (36.8ºC) 
• Heart rate: 156 beats/min
• Respiratory rate of 30 breaths/min
• Capillary refill approximately 3 to 4 seconds
• Buccal mucosa dry
• Eyes sunken
• Reduced skin turgor  
• Patient is crying and resisting examination

This 2-year-old toddler was brought to the pediatric emergency department this evening by her parents. Parents report a 5-day history of diarrhea and estimate the child has had six to eight episodes of watery diarrhea and only two wet diapers today. Patient has a decreased appetite, but has been drinking well, including milk, water, and juice. Two other household members had diarrheal illnesses last week. There is no report of vomiting, fever, or recent changes to the diet.

1845:

• Monitor vital signs every 2 hours
• Assess perineal skin every 2 hours; keep clean and dry
• Begin oral rehydration therapy per protocol
• Assess stool losses and begin replacement therapy per protocol
• Advance to regular diet as tolerated