2030 – Client reported a cough and shortness of breath while resting.

The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees.

Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air.

Lung sounds had crackles in all fields.

A rapid response was called because of the unstable vital signs.

Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.