Nurses' Notes "M Day 1, 0800: The client presents to the emergency department
(ED) with shortness of breath. The client states over the last few days their feet
and lower legs have become increasingly swollen. Auscultated Si. $2 with no
murmur detected. Prescence of jugular vein distention is noted. Lung sounds
have bilateral crackles in posterior bases. +2 pedal edema bilaterally in the lower
extremities. The client reports a history of CHF and hypertension. Current
,Medications: Carvedilol 6.25 mg PO BID. lisinopril 20mg PO daily, furosemide 40
mg PO daily 1200: % The client is admitted to the medical-surgical unit for heart
failure exacerbation. Day 2. 1200: Auscultated S1. 52 with irregular rhythm with
no murmur detected. Lung sounds are diminished bilaterally with occasional
crackles. Mucus membranes are pink. +1 pedal edema bilaterally. The client
states dizziness when standing and muscle cramping in the legs. Positive
Chvostek sign is noted. Prescence of hyperactive deep tendon reflexes is
noted.Vital Sigfi Day 1. 0800: Temperature 37.2° C (989° F) Blood pressure 179/92
mm Hg Heart rate 94/min Respiratory rate 22/min Oxygen saturation 94% on
room air Day 2. 1200: Temperature 36.7° C (981° F) Blood pressure 146/72 mm
Hg Heart rate 116/min i} Respiratory rate 18/min Oxygen saturation 98% on
room airD_iagnostic Results Day1,0800: Magnesium 1.9 mEq/L (1.3 to 2.1 mEq/L)
Sodium 142 mEq/L (136 to 145 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL) Creatinine 0.7 mg/dL (0.5 to 1 mg/dL) Day 2.
0800: i} Magnesium 1.1 mEq/L(1.3 to 2.1 mEq/L) Sodium 148 mEq/L (136 to 145
mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL)
Creatinine 1.6 mg/dL (0.5 to 1 mg/dL)e Medication Administration Record Day 1,
0800: Furosemide 80 mg IV TID Docusate 100 mg PO TID PRN constipation
, The nurse should check an arterial blood gas and then request a prescription
for magnesium sulfate.
1. Ask the client to close their eyes.
2. Hold the monofilament at a right angle to the bottom of the client's
foot.
3. Apply force to the monofilament so that it bends against the bottom
of the client's foot.
4. Ask the client to identify the area of the foot where the monofilament
touched.
, 5. Test the monofilament against the client's cheek.
Medical Histog. One
week ago, 0800: History chpresent illness: 78-year-old female presents to office
for routine 6-month check-up. Client reports no problems since their last visit.
Past medical history: rheumatoid arthritis. Crohn's disease. hypertension. Social
history: drinks three glasses of wine per day, occasionally uses marijuana "to
relax," does not exercise. Family history: one parent had osteoporosis and the
other parent had diabetes mellitus. Surgical history: total hysterectomy 10 years
ago. left knee replacement 2 years ago. Current medications: Hydroxychloroquine
200 mg PO daily Prednisone 5 mg PO daily Lisinopril 20 mg PO daily Today. 0800:
History of present illness: Client returns to office for a follow-up on their testing
from last week. Provider educates client that they have osteoporosis and need to
start a new medication. Client educated on new diagnosis and new medication
prescription.Vital Sigfi Today, 0800: Temperature 37° C (986° F) Heart rate 88/min
Respiratory rate 16/min Blood pressure 159/91 mm HgD_iagnostic Results Last
(ED) with shortness of breath. The client states over the last few days their feet
and lower legs have become increasingly swollen. Auscultated Si. $2 with no
murmur detected. Prescence of jugular vein distention is noted. Lung sounds
have bilateral crackles in posterior bases. +2 pedal edema bilaterally in the lower
extremities. The client reports a history of CHF and hypertension. Current
,Medications: Carvedilol 6.25 mg PO BID. lisinopril 20mg PO daily, furosemide 40
mg PO daily 1200: % The client is admitted to the medical-surgical unit for heart
failure exacerbation. Day 2. 1200: Auscultated S1. 52 with irregular rhythm with
no murmur detected. Lung sounds are diminished bilaterally with occasional
crackles. Mucus membranes are pink. +1 pedal edema bilaterally. The client
states dizziness when standing and muscle cramping in the legs. Positive
Chvostek sign is noted. Prescence of hyperactive deep tendon reflexes is
noted.Vital Sigfi Day 1. 0800: Temperature 37.2° C (989° F) Blood pressure 179/92
mm Hg Heart rate 94/min Respiratory rate 22/min Oxygen saturation 94% on
room air Day 2. 1200: Temperature 36.7° C (981° F) Blood pressure 146/72 mm
Hg Heart rate 116/min i} Respiratory rate 18/min Oxygen saturation 98% on
room airD_iagnostic Results Day1,0800: Magnesium 1.9 mEq/L (1.3 to 2.1 mEq/L)
Sodium 142 mEq/L (136 to 145 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L)
BUN 18 mg/dL (10 to 20 mg/dL) Creatinine 0.7 mg/dL (0.5 to 1 mg/dL) Day 2.
0800: i} Magnesium 1.1 mEq/L(1.3 to 2.1 mEq/L) Sodium 148 mEq/L (136 to 145
mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL)
Creatinine 1.6 mg/dL (0.5 to 1 mg/dL)e Medication Administration Record Day 1,
0800: Furosemide 80 mg IV TID Docusate 100 mg PO TID PRN constipation
, The nurse should check an arterial blood gas and then request a prescription
for magnesium sulfate.
1. Ask the client to close their eyes.
2. Hold the monofilament at a right angle to the bottom of the client's
foot.
3. Apply force to the monofilament so that it bends against the bottom
of the client's foot.
4. Ask the client to identify the area of the foot where the monofilament
touched.
, 5. Test the monofilament against the client's cheek.
Medical Histog. One
week ago, 0800: History chpresent illness: 78-year-old female presents to office
for routine 6-month check-up. Client reports no problems since their last visit.
Past medical history: rheumatoid arthritis. Crohn's disease. hypertension. Social
history: drinks three glasses of wine per day, occasionally uses marijuana "to
relax," does not exercise. Family history: one parent had osteoporosis and the
other parent had diabetes mellitus. Surgical history: total hysterectomy 10 years
ago. left knee replacement 2 years ago. Current medications: Hydroxychloroquine
200 mg PO daily Prednisone 5 mg PO daily Lisinopril 20 mg PO daily Today. 0800:
History of present illness: Client returns to office for a follow-up on their testing
from last week. Provider educates client that they have osteoporosis and need to
start a new medication. Client educated on new diagnosis and new medication
prescription.Vital Sigfi Today, 0800: Temperature 37° C (986° F) Heart rate 88/min
Respiratory rate 16/min Blood pressure 159/91 mm HgD_iagnostic Results Last
