You are receiving report from the day shift nurse. S Sarah Adams is a 65-year-old female who was brought
You are receiving report from the day shift nurse. S Sarah Adams is a 65-year-old female who was brought to the ER with c/o tachypnea with retractions and abdominal accessory muscle use, confusion, and bilateral coarse crackles B Mrs. Adams has a h/o HTN, CAD, Type 2 DM, COPD, and is a smoker x’s 25 years. Mrs. Adams states that she has recently quit smoking. A Mrs. Adams was admitted from the ER this afternoon. She continues to be tachypneic, has coarse crackles with lung auscultation and is alert and oriented x’s 2. Current vital signs BP: 100/50, HR 140, RR 30, O2 Sat 90% 4L NC, pain level 3/10. R The patient is on 4L O2 NC, is receiving NS at 125 mL/hr, broad spectrum antibiotics every 12 hours for suspected pneumonia, albuterol nebulizer treatment every 4 hours as needed.Assessment Nursing Diagnosis Planning/Outcome/Goal Statement Rationale Implementation Subjective Data 1 1a. 1a. 2a. Objective Data 2 2b. 1b. 2b.
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