1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
- Admit to the intensive care unit
- Incentive spirometry every 30 minutes while awake
- Notify radiology to obtain the portable chest radiograph (x-ray)
- Administer albuterol via nebulizer
- Apply supplemental oxygen via nasal cannula
- Collect ordered laboratory work (CBC, CMP, blood cultures)
- Perform a complete bed bath with chlorhexidine 2% solution
- Azithromycin 500 mg intravenous piggy-back (IVPB) daily
- Social services consultation
The nurse reviews the physician's orders and plans implementation.
➢ For each potential nursing action, click to specify whether the action is a high priority or a low priority.
- A. Educate the client on using the incentive spirometer
- B. Perform a head-to-toe skin assessment
- C. Notify radiology to obtain the portable chest radiograph (x-ray)
- D. Administer albuterol via nebulizer
- E. Apply supplemental oxygen via nasal cannula
- F. Collect ordered laboratory work (CBC, CMP, blood cultures)
- G. Perform admission medication reconciliation
- H. Perform a complete bed bath
- I. Administer prescribed azithromycin via intravenous infusion
- J. Social services consultation
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