Client arrives via ambulance to Emergency Department, HOB at 90 degrees and labored breathing. Skin is cool and diaphoretic. Vital signs completed per triage note. Client’s partner is present and is assisting with the interview.

Time: 6:52 am

Client arrives via ambulance to Emergency Department, HOB at 90 degrees and labored breathing. Skin is cool and diaphoretic. Vital signs completed per triage note. Client’s partner is present and is assisting with the interview. Client was diagnosed with viral pneumonia 3 days ago and respiratory symptoms have worsened. Client unable to move from ambulance stretcher to  bed without assistance. Client is alert to person and place only, but can follow simple commands. Bed in lowest position, side rails fully raised, call bell within reach. Partner at bedside.

Time: 7:15 am

Client examined by an attending physician. 3 day history of productive cough, low-grade fever, and increased weakness. Lungs with diffuse crackles in all lobes, pleuritic pain. Heart rhythm with S3 gallop, +2 pedal edema in lower extremities. Decreased appetite. Skin turgor > 3 seconds.

Client has a history of smoking 1 ppd x 10 years. Immunizations reported UTD. NKDA or seasonal allergies. Medications: Oseltamivir as ordered, albuterol inhaler prn dyspnea.

7:40 am  

Electrocardiogram: sinus tachycardia with ST segment changes.

8:05 am  

Chest x-ray: bilateral diffuse alveolar opacities with dependent atelectasis, cardiomegaly, Kerley B lines.

• CBC
• Chem profile
• LFT
• ABG
• D-dimer
• Troponin
• PT, PTT
• Blood cultures
• Chest Xray
• BNP
• EKG
• IV angio
• Oxygen 2L NC to keep saturation >95%