History and Physical Nurses' Notes Flow Sheet Imaging Studies 0730 The nurse assumes care for a 77-year-old female client who was admitted to the medical-surgical unit from the emergency department (ED). The client's admitting diagnosis is pneumonia. The client has a productive cough with green phlegm. Dyspnea and bilateral diminished breath sounds are noted. Client reports shortness of breath and chills. Client is agitated but oriented to person, time, place, and situation. Administered acetaminophen prescribed for temperature greater than 101° F. Radiology report received. Notified healthcare provider regarding client status and radiology report. Vital signs: temperature 102.2° F (39° C), pulse 82 beats/minute and regular, respirations 28 breaths/minute and labored, BP 138/88 mmHg, oxygen saturation 91% on 3 L oxygen via nasal cannula. 0800 Reassessed vital signs and increased oxygenation. For each nursing action, click to specify the findings that support the action as appropriate for the care of this client. Each nursing action may be supported by more than one finding to support the nursing action. Each category must have at least one response option selected. Nursing Action Position client with head of bed elevated 30 to 45 degrees. Administer supplemental oxygen as prescribed. Educate client regarding risks for recurring respiratory infections and oxygenation issues. Findings That Support Nursing Action Temperature 102.2 °F (39 °C) Bilateral diminished breath sounds. L Oxygen saturation 91% on 3 L oxygen via nasal cannula Respiratory rate 28 with labored respirations Radiology report Shortness of breath Pulse 84 and regular Oxygen saturation of 95% on 4 L oxygen via nasal cannular 77 years of age History of asthma Change in respiratory rate from 28 to 24 breaths per minute Client statement that she smokes half a pack of cigarettes per day
History and Physical Nurses' Notes Flow Sheet Imaging Studies 0730 The nurse assumes care for a 77-year-old female client who was admitted to the medical-surgical unit from the emergency department (ED). The client's admitting diagnosis is pneumonia. The client has a productive cough with green phlegm. Dyspnea and bilateral diminished breath sounds are noted. Client reports shortness of breath and chills. Client is agitated but oriented to person, time, place, and situation. Administered acetaminophen prescribed for temperature greater than 101° F. Radiology report received. Notified healthcare provider regarding client status and radiology report. Vital signs: temperature 102.2° F (39° C), pulse 82 beats/minute and regular, respirations 28 breaths/minute and labored, BP 138/88 mmHg, oxygen saturation 91% on 3 L oxygen via nasal cannula. 0800 Reassessed vital signs and increased oxygenation. For each nursing action, click to specify the findings that support the action as appropriate for the care of this client. Each nursing action may be supported by more than one finding to support the nursing action. Each category must have at least one response option selected. Nursing Action Position client with head of bed elevated 30 to 45 degrees. Administer supplemental oxygen as prescribed. Educate client regarding risks for recurring respiratory infections and oxygenation issues. Findings That Support Nursing Action Temperature 102.2 °F (39 °C) Bilateral diminished breath sounds. L Oxygen saturation 91% on 3 L oxygen via nasal cannula Respiratory rate 28 with labored respirations Radiology report Shortness of breath Pulse 84 and regular Oxygen saturation of 95% on 4 L oxygen via nasal cannular 77 years of age History of asthma Change in respiratory rate from 28 to 24 breaths per minute Client statement that she smokes half a pack of cigarettes per day
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
Related questions
Question
Transcribed Image Text:Patient Data
History and Physical Nurses' Notes Flow Sheet
Imaging Studies
不
0730
The nurse assumes care for a 77-year-old female client who was admitted to the
medical-surgical unit from the emergency department (ED). The client's
admitting diagnosis is pneumonia. The client has a productive cough with green
phlegm. Dyspnea and bilateral diminished breath sounds are noted. Client
reports shortness of breath and chills. Client is agitated but oriented to person,
time, place, and situation. Administered acetaminophen prescribed for
temperature greater than 101° F. Radiology report received. Notified healthcare
provider regarding client status and radiology report.
0800
Reassessed vital signs and increased oxygenation.
Vital signs: temperature 102.2° F (39° C), pulse 82 beats/minute and regular,
respirations 28 breaths/minute and labored, BP 138/88 mmHg, oxygen saturation
91% on 3 L oxygen via nasal cannula.
The nurse reviews the nurses' notes, history and physical, and flow sheet to develop the plan of care.
For each nursing action, click to specify the findings that support the action as appropriate for the care of this client.
Each nursing action may be supported by more than one finding to support the nursing action. Each category must
have at least one response option selected.
Nursing Action
Position client with head of bed
elevated 30 to 45 degrees.
Administer supplemental
oxygen as prescribed.
Educate client regarding risks
for recurring respiratory
infections and oxygenation
issues.
Findings That Support Nursing Action
Temperature 102.2 °F (39 °C)
Bilateral diminished breath sounds
Oxygen saturation 91% on 3 L oxygen via nasal cannula
Respiratory rate 28 with labored respirations
Radiology report
Shortness of breath
Pulse 84 and regular
Oxygen saturation of 95% on 4 L oxygen via nasal cannula
77 years of age
History of asthma
K
Change in respiratory rate from 28 to 24 breaths per minute
Client statement that she smokes half a pack of cigarettes per day
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