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Download DocumentThe nurse reviews the Nurses' Notes for a client with asthma who had an outpatient procedure earlier in the day noting new entries for 1500 and 1530.
Nurses' Notes
1415: Client was brought to the emergency department with a report of pain from an outpatient procedure earlier in the day. Rates pain at a level of 8 on a 1 to 10 scale, BP 124/78 mmHg, P 88 beats/min, and RR of 30 breaths/min. Client had history of asthma. Client states no pain medication was sent home. Client appears anxious.
1430: Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5.
1500: Contacted healthcare provider for pain medication. Received order for naproxen
The nurse is caring for a client who has been admitted with fever of undetermined origin. The nurse is reviewing the client's care note to prepare for healthcare provider orders.
Nurses' Notes
0900: Client is alert and oriented. Client reports chills. Skin is dry but warm to touch.Lungs sounds are clear on the right but has crackles on the left. Client has non-productive cough.
1200: Client reports shortness of breath, wheezing and itchy skin. Hives are noted. O2 at 2 L per nasal cannula applied. Head of bed elevated. Intravenous antibiotic stopped.
{Ans: Parameters to Monitor:
-Provide Albuterol Inhaler
- Administer epinephrine parentally.
Potential Condition:
Allergic Reaction
Nursing Actions:
- Respiratory Rate
- Pulse Ox}
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